CLINICAL Dysphagia: Cerebral Palsy (Children)

REVIEW
Indexing Metadata/Description
› Title/condition: Dysphagia: Cerebral Palsy (Children)
› Synonyms: Swallowing disorder: cerebral palsy; deglutition: cerebral palsy; oral
dysphagia: cerebral palsy; pharyngeal dysphagia: cerebral palsy; esophageal dysphagia:
cerebral palsy; difficulty swallowing: cerebral palsy; dysphagia, oral: cerebral palsy;
dysphagia, pharyngeal: cerebral palsy; dysphagia, esophageal: cerebral palsy; swallowing
difficulty: cerebral palsy; cerebral palsy: dysphagia; cerebral palsy: swallowing disorder;
cerebral palsy: deglutition disorder; cerebral palsy: oral dysphagia; cerebral palsy:
pharyngeal dysphagia; cerebral palsy: esophageal dysphagia; cerebral palsy: difficulty
swallowing; palsy, cerebral: dysphagia; palsy, cerebral: swallowing disorder; palsy,
cerebral: deglutition disorder; palsy, cerebral: oral dysphagia; palsy, cerebral: pharyngeal
dysphagia; palsy, cerebral: esophageal dysphagia; palsy, cerebral: difficulty swallowing
› Anatomical location/body part affected: Cerebral palsy (CP) affects the entire
individual; dysphagia results from impairments of the mouth, oropharynx, pharynx, and/
or esophagus
› Area(s) of specialty: Swallowing and Swallowing Disorders; Pediatric Genetic and/or
Neurological Disorders; Infant Feeding and Feeding Disorders
› Description: CP is a condition characterized by considerable motor impairment
that results from a nonprogressive lesion in an immature brain. In addition to motor
impairments, patients with CP sometimes exhibit cognitive and/or communication
impairments. Dysphagia is common among children with CP.(48) The effects of CP on
communication and swallowing are wide-ranging(1)
› ICD-9 codes
• 787.20 dysphagia, unspecified
• 787.21 dysphagia, oral phase
• 787.22 dysphagia, oropharyngeal phase
• 787.23 dysphagia, pharyngeal phase
Author • 787.24 dysphagia, pharyngoesophageal phase
Amory Cable, PhD, CCC-SLP • 787.29 neurogenic dysphagia
American Speech-Language-Hearing
Association (ASHA)
› ICD-10 codes
• G80.0 spastic quadriplegic cerebral palsy
Reviewers • G80.1 spastic diplegic cerebral palsy
Natasha Kanapathy, MA, CCC-SLP • G80.2 spastic hemiplegic cerebral palsy
Cinahl Information Systems, Glendale, CA
• G80.3 athetoid cerebral palsy
Heather Wiemer, MA, CCC-SLP
Cinahl Information Systems, Glendale, CA
• G80.4 ataxic cerebral palsy
Rehabilitation Operations Council
• G80.8 other cerebral palsy
Glendale Adventist Medical Center, • G80.9 cerebral palsy, unspecified
Glendale, CA
• R13.0 aphagia; inability to swallow
• R13.10 dysphagia, unspecified
Editor
Sharon Richman, MSPT
• R13.11 dysphagia, oral phase
Cinahl Information Systems, Glendale, CA • R13.12 dysphagia, oropharyngeal phase
• R13.13 dysphagia, pharyngeal phase
• R13.14 dysphagia, pharyngoesophageal phase
December 29, 2017 • R13.19 other dysphagia

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_
(ICD codes are provided for the readers’ reference, not for billing purposes)
› Reimbursement: Reimbursement for procedure will depend on insurance contract coverage; no specific issues or
information regarding reimbursement have been identified
› Presentation/signs and symptoms: Dysphagia refers to difficulty swallowing due to an inability to move food and/or
liquid efficiently during the oral, pharyngeal, and/or esophageal phases of swallowing.(2) The oral phase includes sucking,
chewing, and moving the food or liquid into the throat. The pharyngeal phase is the initiation of the swallowing reflex, when
the food is squeezed down the throat and the airway is closed off to prevent aspiration (food or liquid entering the airway)
or choking. In the esophageal phase, the openings at the top and bottom of the esophagus move the food or liquid to the
stomach by relaxing and tightening.(3) Dysphagia in individuals with CP is multifaceted and typically results from poor
coordination and control of the muscles involved in swallowing.(48) Children with CP typically experience problems in at
least one, and usually more than one, phase of swallowing.(48) Due to oral motor impairments, children with CP are most at
risk for impairments in the oral phase of swallowing.(4) Pharyngeal phase impairments might include nasal aspiration, slow
swallow initiation, aspiration before and after swallow, laryngeal penetration, and cricopharyngeal dysmotility.(4) In addition,
dysphagia symptoms are often exacerbated by the presence of gastroesophageal reflux disease (GERD), which is common
among children with CP.(50) The following are commonly reported oral and pharyngeal phase swallowing symptoms in
children with CP:(4)
• Oral phase(5)
–Limitation of tongue movement in order to manipulate solid food(4)
–Tongue thrusting and pumping(4)
–Poor expulsion of liquid from a nipple during bottle-feeding(4)
–Oral phase delays(4)
–Oral hypersensitivity(4)
–Prolonged and exaggerated bite reflexes(4)
–Poor functioning of cheek and lip musculature(4)
–Poor lip seal(4)
–Difficulty sipping from a cup(46)
–Drooling(4)
–Temporomandibular joint contracture(4)
–Difficulty biting and masticating solid foods(46)
–Bruxism (habitual, nonfunctional, forceful clenching of the teeth)(51)
- In a study conducted in Brazil with 389 charts of children with developmental disabilities, researchers found that
bruxism was common among these children. The prevalence of bruxism was higher among those children that exhibited
involuntary movements, had GERD, and were male(51)
• Pharyngeal phase
–Nasal aspiration(4)
–Delayed initiation of swallow(4)
–Multiple swallows are needed to clear pharyngeal residue(4,49)
–Piecemeal deglutition(4)
–Hyperactive and hypoactive gag reflexes(4,49)
–Aspiration before, during, or after the swallow(4)
- Common signs of aspiration and pharyngeal dysfunction in children with CP are coughing, wetness of the voice, and
wet breath sounds(49)
–Aspiration with liquids more common than aspiration with food(4)
–Absent or reduced cough reflex after aspiration(4)
 –Cricopharyngeal dysmotility(4)

Causes, Pathogenesis, & Risk Factors

› Causes
• The prevalence of dysphagia in children with CP has been reported to range from 58% to 90%.(5) In one particular study
conducted in the Netherlands with 166 children with severe CP, the prevalence of dysphagia was 99%.(5) Children with
CP exhibit various swallowing disorders, including drooling, impaired sucking, oral stage abnormalities (e.g., delayed
oral phase, nasal aspiration), impaired pharyngeal motility, aspiration, and absent cough after aspiration.(6) Feeding and
swallowing impairments range from mild to severe(7)
› Pathogenesis
• There are four primary types of CP: spastic, choreoathetoid, ataxic, and mixed. Children with spastic diplegia (primarily
lower limb involvement) are most likely total oral feeders with normal cognitive skills. Children with choreoathetoid CP
exhibit spontaneous, uncontrolled, and sometimes ballistic (abrupt and jerky) use of muscles. Poor coordination and shaky
movements are characteristics of ataxic CP. Children with spastic quadriplegia have weak and stiff muscles and have the
most severe functional impairments.(8) Children with spastic quadriplegia are most at risk for swallowing disorders due
to their dependency on others for feeding, difficulties with communication, and associated problems such as epilepsy and
postural problems.(4) Health complications due to swallowing difficulties include aspiration pneumonia, chronic lung
disease, and malnutrition(9)
› Risk factors (for CP)
• Premature birth(1,10)
• Birth after in vitro fertilization(44)
• Low birth weight(1,10)
• Prolonged labor(1)
• Menkes syndrome(1)
• TORCH syndrome(1)
• Intraventricular hemorrhage during infancy(1)
• Cerebral anoxia(1)
• Trauma(1)
• Breech births(10)
• Multiple births(10)
• Toxic substances (babies of mothers exposed to toxins during pregnancy are at increased risk)(10)
• Mother’s health (women who have thyroid problems, intellectual disabilities, or seizures are at increased risk of having a
baby with CP)(10)
• Congenital lymphocytic choriomeningitis virus (LCMV) infection(45)
› Risk factors (for a swallowing and feeding disorder associated with CP)
• Spastic quadriplegia (children with quadriplegia are more likely to exhibit swallowing disorders than those with diplegia)(8)
• Presence of abnormal tone, movement, or reflexes (e.g., asymmetrical tonic neck reflex [ATNR])(4)
• Increased severity of motor impairment(4,11,43,46)

Overall Contraindications/Precautions
› Symptoms associated with CP vary widely, and precautions will vary according to the individual patient and the severity of
accompanying language, cognitive, and/or motor impairments. CP and feeding difficulties are often diagnosed in very young
children; therefore, precautions to evaluation will also be determined by the patient’s age and family concerns. Patients who
are very young or who present with speech/language impairments might not be able to answer questions regarding medical
history. For detailed information on speech-language assessment and treatment with patients with CP, seeClinical Review…
Cerebral Palsy: Speech Therapy; CINAHL Topic ID Number: T708777. It is recommended that parents and/or caregivers be
involved in all assessment procedures
› To conduct a feeding and swallowing evaluation and to provide swallowing treatment for a child with CP, speech-language
pathologists (SLPs) are required to have graduate, postgraduate, or continuing education training specifically in pediatric
dysphagia assessment and treatment(6)
› To perform videofluoroscopic swallowing studies (VFSS), SLPs must have established competencies in the use and storage
of barium used in a VFSS(12)
› Children with dysphagia are at risk for insufficient food/liquid intake, stunted skeletal growth, poor weight gain, anemia,
dental problems, nutritional deficiencies, aspiration, and/or penetration of oral intake.(4) Early assessment of swallowing in
children with CP is indicated to detect these potential problems and implement early intervention programs.(4) Ensure that
the patient and family/caregivers are aware of the risks associated with feeding and swallowing disorders(4)
› Monitoring of swallowing function is recommended because children with CP might initially demonstrate normal feeding
skills and develop swallowing problems later in development(4)

Examination
› Contraindications/precautions to examination
• Assessment should include observation of the mealtime routine and interactions between the caregiver and child at home
• Dysphagia assessment and treatment are best performed using a team approach. The following health professionals are
often involved in the management of swallowing dysfunction in children in rehabilitation and hospital settings: SLP, nurse,
lactation consultant, early childhood nurse, dietician, pediatrician, occupational therapist (OT), physical therapist (PT),
gastroenterologist, neurologist, behavioral psychologist, and social worker.(4) In school settings, the assessment team might
include the parents, an SLP, an OT, a PT, a nurse, a teacher, the school principal, a paraprofessional, the cafeteria manager,
and a social worker(13)
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness: The diagnosis of CP is often difficult in early infancy and might not be
made before the child is 18 months of age(8)
–Course of treatment
- Medical management: Medical management will vary according to the patient’s presenting symptoms. Surgical
intervention to manage GERD is common among children with CP(50)
- Medications for current illness/injury: Determine what medications the physician has prescribed; are they being
taken? Medications for patients with CP might include botulinum toxin injections (to reduce spasticity), glycopyrrolate
(to reduce drooling), antireflux medications, and antiseizure medications(1)
- Diagnostic tests completed: Usual tests for this condition are the following:
- Clinical bedside swallowing examination (BSE) (including parent/caregiver interview)
- Instrumental swallowing examination (e.g., VFSS, endoscopic assessment of swallowing function, ultrasonography)
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether or not they help
- Previous therapy: Document whether the patient has had occupational, speech, or physical therapy for this or other
conditions and what specific treatments were helpful or not helpful
–Aggravating/easing factors
- Does the patient have hearing or vision difficulties?
- Does the patient speak another language?
- What modality does the patient use to communicate?
- How does the patient’s motor impairment affect communication?
- Does the feeding environment encourage the child’s stability and position for self-feeding?(4)
- Is the feeding environment calming or distracting?(4)
- Is the child currently being fed by mouth or is the child tube fed (orogastric, nasogastric, gastronomy, jejunostomy)?(14)
- Does the patient have GERD?(14)
- Is the caregiver/family aware of patient’s specific swallowing difficulties?
- How does the caregiver/family respond to the child’s symptoms of dysphagia? Are mealtimes stressful?
- Does the child have any specific food aversions or aversion towards eating?
 –Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document the nature of symptoms associated with dysphagia. See Presenting signs/symptoms,
above for information
–Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night; does drooling or aspiration of saliva interrupt sleep?
–Other symptoms: Document other symptoms patient might be experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician or social worker (dizziness, bowel/bladder dysfunction,
saddle anesthesia)
–Respiratory status: Note history of respiratory status and current respiratory status for any indication of aspiration. Note
any history of respiratory disorder
–Psychosocial status: Document any behavioral symptoms that could indicate psychosocial disturbances
–Hearing: Document hearing ability, including history of ear infections or ear tubes as well as use of hearing aid(s) or
cochlear implant(s)
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe ___________________________
• Medical history
–Past medical history: A complete medical and developmental history should be obtained as part of a comprehensive
swallowing evaluation. A developmental history should include questions about when a child began sitting, crawling,
standing, and walking independently. Information should also be gathered on fine motor development, speech and
language development, and feeding development as well as any medical signs of swallowing dysfunction (e.g., history of
chest infections, high fevers)
- Previous history of same/similar diagnosis: Is there a history of developmental delay in any area?
- Comorbid diagnoses: Ask the patient or caregiver about other problems, including epilepsy, postural problems, vision
loss (including cortical blindness), and hearing loss
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask the patient or patient’s family about other symptoms the patient is experiencing
• Social/occupational history
–Patient’s goals: Document what the patient and important people in the patient’s life (i.e., family, school staff) hope to
accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any: Things to consider include: Does the patient currently
receive intervention services? If so, are they home, school, or clinic based? Does the patient attend daycare or school?
Does the patient work? If the patient is in school, what support services are in place? With whom does the patient eat?
Where does the patient eat? What types/textures of food? What is the patient’s eating schedule?
–Functional limitations/assistance with ADLs/adaptive equipment: Obtain information on adaptive equipment the
patient is using, such as assistive/alternative communication devices, wheelchairs, walkers, hearing aids, glasses, or
adaptive eating equipment
–Living environment: Number of stairs, number of floors in home, with whom the patient lives (e.g., siblings, caregivers).
Identify if there are barriers to independence in the home; any modifications necessary?
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Arousal, attention, cognition (including memory, problem solving): If present, cognitive deficits associated with CP
can range from mild to severe. The evaluating or treating SLP should note the results of any neurological (MRI, CT),
neuropsychological, or psychological/cognitive tests that have been completed
• Assistive and adaptive devices: Document use of any adaptive devices for communication, feeding, or body positioning
• Ergonomics/body mechanics: Note any difficulties with positioning and body mechanics that might interfere with
feeding. Collaborate with PT and/or OT as necessary
• Motor function (motor control/tone/learning): Examine motor function as it relates to swallowing and
self-feeding.Collaborate with the PT and/or OT as necessary
• Oral mechanism exam and related tests: Complete an oral mechanism examination as part of every swallowing
evaluation. Document abnormalities and asymmetries in muscle tone and strength as well as any reduced lingual or labial
range of motion. Oral abnormalities commonly observed in children with CP include:
–Limited tongue movement resulting in difficulty manipulating solid food(4)
–Tongue thrusting and pumping(4)
–Oral hypersensitivity(4)
–Poor functioning of cheek and lip musculature(4)
–Prolonged and exaggerated bite reflexes(4)
–Temporomandibular joint contracture(4)
–Drooling(4)
–Poor lip seal(4)
–Bruxism(51)
• Posture: Note posture for eating/feeding. Collaborate with PT and/or OT as necessary to assist child in attaining efficient
posture for feeding
• Speech and language: Children with CP often have speech and language disorders. Assess verbal and/or nonverbal
communication as needed. For detailed information on speech-language assessment and treatment with patients with CP,
see Clinical Review…Cerebral Palsy: Speech Therapy, referenced above
• Special tests specific to diagnosis
–BSE: There are several clinical assessment scales and checklists to evaluate infants and children; however, no universally
accepted feeding assessment tool exists. Scales, surveys, and checklists are commonly used in the clinical examination
but often do not include normative data, standardization, validation, or guidelines for interpretation. SLP knowledge of
normal oral motor development and feeding function are essential when evaluating infants and children.(4)A BSE cannot
definitively confirm the presence or absence of aspiration. For detailed information on a BSE for children, see Clinical
Review…Dysphagia Assessment: In-depthBedside Swallow Examination (Pediatrics); CINAHL Topic ID Number:
T709064
- In a systematic review of objective measures for oropharyngeal dysphagia, authors identified 9 objective measures with
published psychometric data in children with CP or other neurodevelopmental disabilities aged 12 months to 5 years.
The validity of each of these measures (for children with CP) was assessed and found to be low—the highest score was
5/12.(40) The following is a list of the objective measures identified in this systematic review:
- Schedule for Oral Motor Assessment (SOMA): An instrument that assesses oral-motor function across a wide range of
food textures and fluids for preverbal children; found to have the highest level of psychometric rigor and clinical utility
in this review and also had the highest score for validity in children with CP(40)
- Functional Feeding Assessment, modified (FFAm): A subset of the Multidisciplinary Feeding Profile, a statistically
based protocol for patients who are dependent feeders. Scaled ratings are made for posture, tone, reflexes, general
motor control, orofacial structures, orofacial sensory input, orofacial motor control, ventilation in the FFAm.(19)
Authors of the systematic review found that the FFAm, along with the SOMA, had the highest level of psychometric
rigor(40)
- Dysphagia Disorders Survey (DDS):A standardized screening survey that can be used with children from 2 years of
age to adults. Assesses body mass index (BMI), restrictions in food textures and viscosity, dependence in feeding, and
need for special utensils or positioning. Provides information on the severity of the swallowing disorder and can be
used as an outcome measure.(22) Along with the SOMA, the authors of the systematic review found the DDS to have
the greatest clinical utility for children with CP(40)
- Brief Assessment of Motor Function – Oral Motor Deglutition Scale: Consists of 0- to 10-pointhierarchical scales
designed for rapid assessment of gross, fine, and oral motor skills(41)
- Behavioral Assessment Scale of Oral Functions in Feeding: This scale measures variations of 9 feeding-related
behaviors (e.g., jaw closure, lip closure, swallowing, tongue control, chewing skills). Behaviors are rated on a scale
from 0 (totally passive response) to 5 (functionally normal response)(42)
- Feeding Behaviour Scale (FBS): A scale consisting of 6 feeder behaviors and 14 child behaviors; each behavior is
scored as “normal,” “marginal,” or “inadequate”(40)
 - Gisel Video Assessment(GVA): An evaluative video-based assessment scored based on the administration of puree,
soft solid, and viscous trials; time(s), cycles, and time-cycle ratio are scored and compared to age-equivalent normative
data(40)
- Oral Motor Assessment Scale (OMAS): An ordinal scale with scores of 0 (passive) to 3 (normal); scores 7
behaviors(40)
- Pre-Speech Assessment Scale (PSAS):A rating scale that examines swallowing and voice in children up to 2 years of
age. Ratings include duration of the meal, amount of intake, food consistencies, positioning, sucking from a nipple,
sipping from a cup, and coordination of suck-swallow-breath(17)
- In a study conducted in Australia with 130 children with CP aged 18 to 36 months, researchers investigated which
measures of dysphagia were the best for discriminating between those children with and without oropharyngeal
dysphagia. Researchers evaluated the SOMA, DDS, and PSAS and found that all three measures had strong agreement
with respect to inter- and intrarater reliability. In this study, the SOMA was found to have the best specificity (100.0%)
but lacked sensitivity (53.0%), and both the DDS and PSAS had high sensitivity (each 100.0%) but lower specificity
(47.1% and 70.6%, respectively)(47)
- Additional objective measures of swallowing ability
- Clinical Feeding Evaluation of Infants (CFEI) scale: Evaluation of an infant’s ability to suck on a bottle
and/or breast. Includes assessment of child’s feeding history, oral motor skills, oral tactile responses,
suck-swallow-breathcoordination, general motor control, and general physical state during feeding and swallowing(15)
- Neonatal Oral Motor Assessment Scale (NOMAS): Evaluation of sucking in infants (up to 3 months of age). Aspects
of sucking behavior are classified as normal, disorganized, or dysfunctional(16)
- Oral-Motor/Feeding Rating Scale: Lip, cheek, tongue, and jaw movement are rated during a typical meal. This scale
can be used with children from 1 year of age through to adults(18)
- Assessment Scale of Oral Functions in Feeding: Ratings of lip, jaw, and tongue movement during ingestion of liquids
and solid foods. Assessment of sipping from a cup, coughing, gagging, and hypersensitivity associated with feeding
and swallowing. A checklist allows for indication of abnormal oral structures, oral reflexes, positioning, diet, utensils,
and feeding(20)
- Preschool Motor Speech Evaluation: Assessment of oral motor, oral sensory and oral motor speech abilities in children
from 18 months to 5 years(21)
- Nutrition and Swallowing Checklist: A tool developed to screen nutrition and swallowing problems in persons with
intellectual disabilities. The checklist format allows for caregiver involvement in identifying risks and managing
swallowing difficulties(23)
–VFSS/modified barium swallow (MBS)/videofluoroscopic examination (VFE): A VFSS is performed when the dysphagia
team has concerns about the pharyngeal phase of swallowing and the complete swallowing sequence. A VFSS is
completed in collaboration with a physician (radiologist or physiatrist).(6) Most clinical practices follow the protocol
originally described by Logemann(24) and adaptations of this protocol for infants and children are described in Arvedson
and Lefton-Greif(25)
- The assessment must be age appropriate with regard to positioning, presentation, and viscosity of material.(6) The
patient eats and drinks a variety of developmentally appropriate liquids and solids mixed with barium while images
are recorded with videofluorography. All patients should be examined in the lateral and frontal positions to provide
information on movements of the swallow and symmetry of bolus flow and pharyngeal wall contraction. The SLP
examines for aspiration and the effectiveness of presenting different food consistencies or modifying posture.(6) In
contrast to the BSE, a VFSS provides critical information on the pharyngeal phase of the swallow (e.g., movement of
the hyolaryngeal complex, confirmation of the presence of aspiration)(26)
- Given the unnatural surroundings, swallowing function observed during a VFSS is not necessarily identical to that
present at mealtimes.(27) Other variables that influence swallowing function include anxiety, fatigue, and medications(28)
- Due to the potential harmful effects of ionizing radiation on children, a repeat VFSS should only be considered when
there are specific questions that require answers from a repeat study; a VFSS should not be used frequently to monitor
changes in swallowing(8)
- For detailed information on MBS/VFSS assessment in children, see Clinical Review…Dysphagia Assessment: Modified
Barium Swallow (Pediatrics); CINAHL Topic ID Number: T709077
 - During the VFSS, the following physiologic components can be observed:(28)
- Lip closure (ability to contain a liquid bolus)
- Lingual elevation (the back of the tongue is slightly elevated)
- Tongue-to-palatal seal
- Bolus preparation/mastication
- Bolus transport/movement of the tongue (movement of the bolus to the back of the oral cavity)
- Initiation of the pharyngeal swallow (swallow should be initiated when the bolus reaches the region of the posterior
oral cavity)
- Soft palate elevation and retraction
- Laryngeal elevation
- Anterior hyoid excursion
- Pharyngeal contraction
- Pharyngoesophageal segment opening
- Tongue base retraction
- Epiglottic inversion
- Esophageal clearance
–Endoscopic assessment of swallowing function/fiberoptic endoscopic evaluation of swallowing (FEES): FEES is
performed to evaluate the anatomy and physiology of the pharynx and the larynx, pharyngeal swallow function, and the
patient’s ability to manage secretions and swallow foods and liquids as well as document the presence of aspiration.(6)
In addition, it can be used to explore a variety of diagnostic interventions, such as varying bolus consistency, varying
posture, or making use of visual feedback for reinforcement.(29) After the insertion of the endoscope, the patient
can engage in normal feeding behavior during the evaluation. Food must be light in color to enhance visibility (e.g.,
milk, puddings, yogurt, bread). FEES is preferred over VFSS when patients have safety issues related to radiation
exposure or when they need retesting. Due to the invasive nature of the procedure, it might be difficult to obtain accurate
representation of a normal swallow in young children.(4) The American Speech-Language-Hearing Association has
published several online documents relevant to the technical aspects of FEES and the qualifications required to perform
FEES.(30) For detailed information on FEES and endoscopic examinations for dysphagia, see Clinical Review…
Dysphagia Assessment: Fiberoptic Endoscopic Evaluation of Swallowing (FEES); CINAHL Topic ID Number: T709038
and Clinical Review…Dysphagia Assessment: Endoscopic Evaluation; CINAHL Topic ID Number: T709141
–Ultrasonography: Infant sucking and oral transit times can be examined by ultrasonography, an instrumental procedure
involving transducers that use high-frequency sound waves to create images. In infants and children, the transducer is
placed under the chin as they swallow liquid or food. The ultrasonographic scanner can display images of the nipple,
tongue surface, hard and soft palates, and hyoid during infant feeding.(6) Ultrasound data on children with CP have
indicated that they have prolonged oral transit times and they manage solid boluses better than liquid boluses. In addition,
children with CP manage smaller liquid boluses more easily than those that are larger(4)
–Pulse oximetry: Oximetry is used to evaluate hemoglobin oxygen saturation levels before and after feeding. Most infants
have an oxygen saturation level of at least 95%. Low saturation levels (below 90%) indicate some degree of hypoxia.(31)
Hypoxia might occur in children with CP during oral feeding due to abnormal respiratory rate or excessive fatigue during
meals
–Cervical auscultation: Cervical auscultation involves the use of a stethoscope on the lateral side of the thyroid cartilage to
listen to sounds associated with breathing and swallowing patterns. One limitation of cervical auscultation includes a lack
of normative data and clear guidelines for interpretation of the procedure. In addition, many movements associated with
swallowing are silent.(4) For detailed information on cervical auscultation in children, see Clinical Review…Dysphagia
Assessment: Cervical Auscultation (Pediatrics); CINAHL Topic ID Number: T709101

Assessment/Plan of Care
› Contraindications/precautions
• Patients with CP are at risk for falls; follow facility protocols for fall prevention and post fall prevention
instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls
and educated about fall prevention strategies. Discharge criteria should include independence with fall prevention
strategies
 • Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to
modalities. Rehabilitation professionals should always use their professional judgment
• Patients with dysphagia are at risk for aspiration and penetration of oral intake. Ensure that the patient and family/
caregivers are aware of potential aspiration risks and are educated about strategies when appropriate
• Feeding and dietary practices vary considerably between families and cultures. It is important for the SLP to understand
the family’s concerns and objectives regarding feeding and swallowing before finalizing any recommendations regarding
specific food types and textures(32)
• Nutritional intake is crucial for the child’s growth, cognition, motor skills, and physical development, and children with CP
are at high risk for growth failure.(9) Thus, decisions regarding dysphagia treatment are best made by a team approach with
the involvement of appropriate specialists and family members(4)
• High levels of parent distress are associated with feeding disorders and clinical/counseling services for families are often
warranted
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
presented below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
› Diagnosis/need for treatment: The patient demonstrates difficulty in feeding or signs of aspiration and/or malnutrition
› Rule out: Distinguish between organic feeding difficulties and feeding difficulties due to food preferences or behavior(33)
› Prognosis: The risk for and severity of dysphagia in children with CP has been found to increase with the severity of the
child’s motor impairment(5)
• In a prospective, longitudinal representative cohort study conducted in Australia with 170 children with CP who were
assessed on 396 different occasions, researchers found that parent-reportedattainment of eating ability was significantly
associated with gross motor functional ability as measured by the Gross Motor Function Classification System (GMFCS)
(a scale used by PTs to assess gross motor skills).(43) The ability of children with CP to consume foods with advanced
textures (e.g., ground, lumpy, cut-up, chunky, all textures) was the best for children whose GMFCS score was level I and
then progressively decreased as the GMFCS score decreased(43)
• In a longitudinal study conducted in Australia with 53 children with CP, researchers assessed swallowing ability at some
point between 18 and 24 months of age and again at 36 months of age. Researchers found that the severity and presence of
dysphagia in this group of children was relatively stable between time points. There was an improvement in or resolution
of dysphagia observed in children with a GMFCS score of I (i.e., those with ambulatory CP). In children with GMFCS
scores between II and V, dysphagia did not resolve, but did improve in about 1/3 of this group. Overall, researchers found
an increased risk of dysphagia, and increased severity of dysphagia with higher GMFCS scores (i.e., lower gross motor
abilities)(53)
› Referral to other disciplines: Dysphagia assessment and treatment is best performed by a team approach. The following
professionals are often involved in the management of swallowing dysfunction in children in medical settings: SLP, nurse,
lactation consultant, early childhood nurse, dietician, pediatrician, OT, PT, gastroenterologist, neurologist, and social
worker.(4) School-based teams for dysphagia management might include the parents, an SLP, an OT, a PT, a nurse, a teacher,
the school principal, a paraprofessional, the cafeteria manager, a teacher’s aide/assistant, and a social worker(13)
› Other considerations: When selecting the child’s swallowing goals, the dysphagia team must also consider the child’s
communication goals. When possible, careful selection of equipment and therapy techniques might assist the child in
working on speech/language goals and feeding goals simultaneously(4)
› Treatment summary: Children with feeding and swallowing difficulties can be served in a variety of settings, including
the child’s home, private practices, hospitals, rehabilitation clinics, and schools. The U.S. Individuals With Disabilities
Education Act (IDEA) of 1999 established that children with dysphagia in the United States have the right to receive
swallowing and feeding services in a public school setting and that school-based SLPs have an ethical and professional
responsibility to ensure that children receive appropriate dysphagia services.(34,35) Dysphagia management for the child with
CP involves a variety of considerations, including the nutritional needs of the child, the feeding environment, the utensils
used for feeding, the texture and type of food, treatment of GERD, the positioning of the child, selection of appropriate
feeding methods, scheduling of meals, the family’s dietary habits, and consideration of the parents’ needs and skills.(4,5)
Timing of meals and medications needs to be carefully considered for children with CP who have epilepsy(4)
• Oral sensory motor therapy: The objectives of oral sensory motor therapy are to increase coordination of oral motor
movements to improve feeding skills and/or to increase normal sensory function during mealtimes. Oral sensory motor
therapy has been found to increase oral motor function (e.g., chewing, tongue lateralization, lip closure), but research is
 inconclusive with regard to its effect on oral feeding efficiency, caloric intake, weight gain, pharyngeal motility, and airway
protection for children with CP(11,36,37)
• Oral appliance therapy: The purpose of oral appliances for children with CP is to improve tongue position and posture.
Oral appliances have been found to increase tongue mobility, improve resting posture of the lips, and improve oral motor
transport. In a study conducted in Canada, researchers examined the effects of oral appliance therapy on children with
CP and moderate dysphagia by comparing one group who continued to wear the appliance after 1 year of therapy (n = 9)
to a control group (n = 8) that discontinued the use of the appliance after the same amount of therapy. Results indicated
that maturation was equally effective as the oral appliance therapy 1 year after termination of the initial therapy. The
authors concluded that oral appliance therapy is effective in improving functional feeding skills in children with moderate
dysphagia but might not be effective for those with more mild dysphagia(38)
• Positioning/postural adaptations: Many children with CP and dysphagia have abnormalities in posture, tone, and
movement that influence feeding.(4) In these cases, the SLP might collaborate with a PT and/or OT in providing a seating
position that is most beneficial for feeding. Positioning has been found to improve oral and pharyngeal swallowing function
in children with CP.(39) Sitting upright for a period of time after eating can decrease the symptoms of GERD
–For detailed information on postural modifications for dysphagia treatment, see Clinical Review…Dysphagia: Swallowing
Therapy – Compensatory; CINAHL Topic ID Number: T903567
• Adaptive equipment: Adaptive equipment for eating and feeding therapy might include specific teats, bottles, pacifiers,
cups, spoons, and forks.(1) The SLP can collaborate with the OT in selecting adaptive equipment for feeding
• Modification of liquids: Liquids can be modified (i.e.,thickened) to assist the child in controlling liquids in the oral
and pharyngeal phases of the swallow and improve the effectiveness and safety of the swallow. Trials of different liquid
consistencies should be performed with instrumental assessments (e.g., VFSS, FEES). Modification of equipment such
as bottles and cups is sometimes necessary to accommodate the thickened liquids, and parents/caregivers should receive
training and information regarding thickened liquids. Examples of circumstances in which thickened liquids might assist
the child include:(4)
–Pooling of liquid in the oral cavity
–Poor lip closure and loss of liquid
–Poor tongue control, movement, and coordination
–Delayed initiation of the swallow
–Coughing/choking/gulping
–Clinical signs of aspiration
–History of chest infections
–Presence of GERD
–For detailed information on liquid modifications for dysphagia treatment, see Clinical Review…Dysphagia: Swallowing
Therapy – Compensatory, referenced above
• Modification of solid foods: Solid foods can be modified to assist the child in chewing and controlling the bolus.
In addition, recommendations of food consistency and food type must be aligned to the family’s dietary habits and
culture. The following guidelines are indicators of age of nutritional readiness and oral skills for solid foods in normal
development; however, the child’s individual oromotor/feeding skills and food allergies must be considered when
introducing new textures of foods:(4)
–6 to 8 months – purees(4)
–8 to 9 months – mashed lumpy/mixed textures(4)
–Finger food
- 7 to 8 months onwards – toast/biscuits(4)
- 10 to 11 months onwards – soft chopped food(4)
- 10 to 12 months onwards – firm finger foods(4)
- 15 months onwards – foods that require sustained biting and chewing(4)
–For detailed information on diet modifications for dysphagia treatment, see Clinical Review…Dysphagia: Swallowing
Therapy – Compensatory, referenced above
• Feeding tubes (orogastric, nasogastric, gastronomy, jejunostomy)/enteral feeding: Children with CP who shown
signs of undernutrition, aspiration associated with respiratory disease, insufficient fluid intake, and excessive stress during
 mealtimes might be candidates for a feeding tube to provide an alternative nutritional source.(9) Other considerations
include the presence of GERD and caregiver stress associated with mealtimes.(14) Successful long-term management of
enteral feeding depends on coordinated longitudinal care of a dysphagia team. Provision of pleasurable experiences to the
mouth and face has been recommended to prevent the child from becoming orally hypersensitive while receiving nutrition
by tube feeding.(4)Evidence for the effectiveness of gastronomy tube feeding for children with CP is insufficient due to
methodological weaknesses of studies and absence of randomized controlled trials.(14,52) Authors of a systematic review
of the literature performed in 2014 reported that all of the studies that have been conducted regarding the effectiveness of
gastrostomy tubes for children with CP have been on children with severe feeding impairment.(52) In these studies, the
researchers all report a significant increase in weight associated with the placement of gastrostomy tube; however, the
frequency of surgical complications and adverse events was high.(52) The decision to place a feeding tube is made by the
physician and the child’s family based on input from the SLP, OT, nutritionist, and other professionals working with the
child

.
Problem Goal Intervention Expected Progression Home Program
Inadequate oral intake Meet nutritional needs Supplementation of The child will meet Feeding program
for nutritional needs oral intake nutritional needs should be implemented
_ at home/school
Children with CP
often require a longer
duration to feed orally
and thus are unable
to receive adequate
nutrition without
supplementation. For a
newborn, an oral feed
should be completed
within 40 to 45 minutes
and by 30 minutes
for a child about 6
months of age. An
SLP might collaborate
with a pediatrician or
nutritionist to assist
the child in meeting
nutritional needs orally
by documenting the
child’s feeding skills
(timing, range of foods,
and consistencies)
to assist in selecting
the correct way to
supplement
_
_
Modifications include:
•Small, frequent feeds
•Adding calories
to feeds by using
commercial additives
•Adding vitamins,
minerals, and
nutritional
supplements
•Using nasogastric
tube feeding methods
in addition to oral
feeding
Prolonged feeding Modify feeding Modification of Progression of Feeding program
times due to disruptive environment to meet feeding environment environmental should be implemented
feeding environment the feeding needs of the _ modifications and at home/school
child The physical specific types of food
environment in which and liquid consistencies
a child is being fed can trialed will vary
have an impact on the according to patient
duration of a meal. The goals
feeding environment
should be a calm setting
in which the child can
focus on feeding and
swallowing. Some
children might respond
to the introduction of
rhythm to assist in the
coordination of sucking
and chewing. Music or
gentle rocking might
assist some children
in achieving better
coordination of these
functions(4)
Abnormalities in the Improve positioning to Modification of the Progression of postural Feeding program
child’s posture/muscle attain a more adequate child’s posture modifications and should be implemented
tone that interfere with feeding position for the _ specific types of food at home/school
feeding child Many children with and liquid consistencies
CP and dysphagia trialed will vary
have abnormalities according to patient
in their posture, tone, goals
and movement that
influence feeding.(4)
In these cases, the
SLP might collaborate
with a PT and/or OT
in providing a seating
position that:
•Is relaxed and
comfortable
and allows for a
sustainable posture/
position(4)
•Provides balance,
stability, and
mobility(4)
•Is efficient and safe for
swallowing(4)
•Inhibits normal
movement patterns
that interfere with
swallowing(4)
•Allows for
independent feeding if
possible
•Provides for optimal
oromotor function and
control(4)
•Reduces likelihood of
fatigue for child and
caregiver.(4) Examples
of positioning
modifications for
newborns include
swaddling, specific
positions (side lying,
prone, more upright),
and use of positioning
aids.(4) For children
who are eating solid
foods, positioning
techniques might
include a pelvic strap
to stabilize pelvis and
hips, a footplate and/or
additional foot cuffs, a
harness to support the
trunk, and head/neck
support with hand or
Feeding difficulties/ Increase the infant’s or Adaptive equipment The choice and Feeding program
dysphagia child’s feeding abilities _ progression of adaptive should be implemented
Adaptive equipment equipment as well at home
for feeding includes as the specific types
specific bottle nipples, of food and liquid
bottles, pacifiers, cups, consistencies trialed
spoons, straws, and will vary according to
forks. When selecting patient goals
special equipment
for feeding, the SLP
should consider early
speech development
and ways to facilitate
that development
through use of special
equipment (training cup
to facilitate lip closure).
Other variables to
consider when selecting
equipment include the
child’s:
•Age and size
•Oral anatomy
•Feeding skills
•Medical status
•Cognitive
development
•Preferences
•Feeding goals
•Motor development
•Positioning for
feeding. In addition,
it is important to
consider parent
preferences as well
as the durability, cost,
and accessibility of
the equipment.(4)
A team approach is
recommended for
selection and trial of
adaptive equipment
with the child(4)
Oral or pharyngeal Increase swallowing
dysphagia due to liquid ability for liquids
consistency
Difficulty with control
or mastication of bolus
in the oral phases
Modification of Progression of Feeding program
liquids specific types of liquid should be implemented
_ consistencies trialed at home/school
Children with CP who will vary according to
experience pooling of patient goals
liquid in the oral cavity,
poor lip closure, poor
tongue coordination,
delayed initiation of
oral and pharyngeal
phases of swallow,
and coughing/choking/
gulping might benefit
from thickened liquids.
In addition, children
who show clinical
signs of aspiration or
who have a history of
respiratory infections
might benefit from
temporary or long-
term use of thickened
liquids.(4) The rationale
for the use of thickened
liquids must be
carefully explained to
caregivers/parents and
confirmed by use of
instrumental evaluation
Increase swallowing Modification of solids Progression of Feeding program
ability for solids _ specific types of food should be implemented
Solid foods might consistencies trialed at home/school
be modified to assist will vary according to
the child in chewing patient goals
and controlling the
bolus. In addition,
recommendations of
food consistency and
food type must be
aligned the family’s
dietary habits and
culture(4)

Desired Outcomes/Outcome Measures

› Safe swallowing for adequate nutrition and hydration(6)
• BSE
• FEES
• Clinical signs of aspiration(4,14)
• Time required for feeding(4,14)
• Performance of the child on specific oral motor activities for feeding (e.g., lip closure, chewing skills)(4,14)
 • Weight of the child or other measures of nutritional status(4,14)
• Growth of child(4,14)
› Minimized risk of respiratory complications(6)
• Absence of chest infections(4,14)
• Clinical signs of aspiration(4,14)
› Maximized quality of life(6)
• Child’s ability to eat different textures/types of food(4,14)
• Quality of life of the child using a scale that has undergone psychometric testing(4,14)
› Due to the potential harmful effects of ionizing radiation on children, a repeat VFSS should only be considered when there
are specific questions that require answers from a repeat study; a VFSS should not be used frequently to monitor changes in
swallowing(8)

Maintenance or Prevention
› Monitoring of swallowing function is recommended because children with CP might demonstrate normal feeding skills and
develop swallowing problems later in development.(4) For example, children with spastic quadriplegia or choreoathetosis
might be oral feeders as young children but require supplemental nutrition in later years. Children who are slow feeders
might also need increased caloric density of foods to meet their nutritional needs(8)

Patient Education
› It is important the dysphagia team educate the parents/caregivers on positioning of the child for feeding, environmental
modifications for feeding, adaptive equipment for feeding, feeding choices and methods, and understanding of the feeding
problem and associated risks.(4) When educating the parent about adaptive equipment, the SLP should:
• Be aware of cultural variations that influence feeding practices
• Assist in helping the parent get access to the equipment when possible(4)
• Explain the rationale for use of the equipment(4)
• Demonstrate the correct use of the equipment(4)
• Provide ongoing monitoring and review of equipment use(4)
› See Patient Information Series from United Cerebral Palsy at http://ucp.org/

Note
› Recent review of the literature has found no updated research evidence on this topic since previous publication on July 22,
2016

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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