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Evaluation of Feeding, Eating, and

Swallowing for Children With Cerebral

Palsy

Kate Barlow, OT, OTD, OTR

Assistant Professor of American International College

Springfield, MA

Kelsey Sullivan, OTS

Occupational therapy student at MGH Institute of Health Professions

Boston, MA

This CE Article was developed in collaboration with AOTA’s Children & Youth

Special Interest Section

ABSTRACT

Most children with cerebral palsy (CP) also have a pediatric

feeding disorder (PFD). Evaluating feeding in children with CP is

a highly complex process that is best done in a team environment.

This article describes the prevalence of PFDs in children with CP

and highlights the special clinical considerations of the occupa-

tional therapist in evaluating PFDs in children with CP.

LEARNING OBJECTIVES

After reading this article, you should be able to:

1. Identify the elements of PFDs resulting from CP that require

special consideration

2. Identify the typical phases of swallowing and the impact of CP

3. Describe the role of the occupational therapist in assessing

each phase of swallow for children with CP.

INTRODUCTION

Eating and swallowing are ADLs that individuals learn to master

to independently function and take care of themselves (American

Occupational Therapy Association [AOTA], 2020). Impairment in

one’s ability to properly and safely complete necessary ADLs may

lead to a decreased perception of their quality of life (QoL) (Ede-

mekong et al., 2020). When a child is born, they must rely on

caregivers to complete basic ADLs; however, as they grow, chil-

dren learn to complete these tasks for themselves. The motivation

to do so is linked to an innate feeling of competence and satis-

faction when successfully completed independently (Shepherd

& Ivey, 2020). When a child is born with a disability, the capacity

to perform certain ADLs may be impaired, thus interfering with

feelings of autonomy, self-esteem, and self-determination (Shep-

herd & Ivey, 2020).

Children born with cerebral palsy (CP), the most com-

monly diagnosed motor disability in children, have “motor,

cognitive, and perceptive impairments” that affect their ability

to complete many ADLs (Erasmus et al., 2012, p. 409). Of

importance, several studies suggest that children with CP have

a particular difficulty in completing various tasks associated

with feeding. Dysphagia, the impaired ability to swallow, is

prevalent in more than half of all children with CP and is the

“leading cause of death in individuals with CP” (Novak et al.,

2020, p. 10). Additionally, children with CP are chronically

classified as malnourished for reasons that include oral motor

dysfunction, chewing disorders, and postural abnormalities

(Inal et al., 2017).

The complexity of CP cases with comorbid conditions, par-

ticularly feeding disorders, requires a qualified team approach

when evaluating and treating for various impairments during

both volitional and reflexive phases of feeding and swallow-

ing. The purpose of this article is to highlight the prevalence

of feeding disorders in children with CP, and the role of the

occupational therapist (OT) in evaluating children with CP

who have feeding difficulties. Evidence-based evaluation and

treatment considerations for this specific population will be

reviewed.

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PREVALENCE OF CP IN THE UNITED STATES AND GLOBALLY

CP is the most common pediatric motor disability in the United

States, affecting approximately 2 per 1,000 live births, or

around 10,000 births a year (Poinsett, 2020). Furthermore, it is

estimated that more than 750,000 children and adults have this

motor disability. Globally, there are approximately 50 million

individuals living with CP who require rehabilitation services

(Cieza et al., 2020).

Although CP is the most commonly diagnosed motor

condition in children, its exact cause has not been identi-

fied (Cerebral Palsy Alliance, 2015). Research has identified

several risk factors associated with high rates of children with

CP, including low birthweight and premature birth, multiple

pregnancies, and maternal infection (Reidy et al., 2020).

Additionally, higher rates of CP are diagnosed in males and

non-Hispanic black children (Stavsky et al., 2017). A child

with CP is diagnosed according to one of four main types,

including spastic (80% to 86% of cases), dyskinetic, ataxic, or

mixed (Stamer, 2016). Hallmark symptoms depend on type,

but they commonly include reduced gross motor skills, poor

postural control, and abnormal muscle tone, which all affect

function (Labaf et al., 2015).

Although not considered hallmark features of the con-

dition, feeding difficulties affect 70% to 80% of children

with CP (Korth & Rendell, 2015). Additionally, drooling and

swallowing difficulties were estimated to affect 44% and 50%

of individuals with CP, respectively. Individuals with more

severe forms of CP and increased impairment in functioning

were found to have a higher prevalence of feeding problems.

Furthermore, those who had difficulties with feeding showed

increased rates of malnutrition and aspiration pneumonia, and

an overall decrease in QoL.

PEDIATRIC FEEDING DISORDERS

Pediatric feeding disorders (PFDs) affect up to 29% of all children

in the United States (Silverman et al., 2020). Despite the preva-

lence of such conditions, there is a lack of awareness and univer-

sally accepted definition for PFDs. With influence from the World

Health Organization’s International Classification of Functioning,

Disability and Health, the following definition is proposed: PFDs

are “impaired oral intake that is not age appropriate and associ-

ated with medical, nutritional, feeding skill, and/or psychosocial

dysfunction” (Goday et al., 2019, p. 124). With this definition in

mind, PFDs are clearly complex in nature and require a holistic

and collaborative approach to evaluation and treatment.

PFDs may encompass one or more impairments within the

domains of medical, nutritional, feeding skills, and/or psy-

chosocial dysfunction, thus requiring the child’s physician to

obtain further information from a range of medical specialists,

including, but not limited to, an allergist, dentist, gastroenter-

ologist, dietician, psychologist, speech-language pathologist

(SLP), and OT (Marcus & Breton, 2013). These specialists aid

in the comprehensive evaluation process and perform tests to

assess feeding and swallowing ability, along with the potential

for comorbid conditions.

When addressing the nutritional needs and potential dys-

function of this area, a registered dietitian (RD) is often needed.

An RD will assess whether a child is obtaining the necessary

calories, fluids, and other vital nutrients for optimal growth and

functioning, as well as recommend a modified diet when appro-

priate (Marcus & Breton, 2013). This specialist has expertise

in creating a well rounded and tolerated diet for the child and

works collaboratively with SLPs and OTs for effective feeding

skill development.

The role of OTs in pediatric feeding will be further discussed

in detail in the following section; however, they play a crucial

role, along with SLPs, in aiding a child with CP to properly

develop the necessary skills to feed successfully.

Last, psychosocial dysfunction may present not only in the

child with a PFD, but also in the parents, caregivers, and family

members who tend to the child. A psychologist or psychiatrist

may evaluate the child and caregivers’ mealtime behaviors to

identify strategies to increase positive feeding experiences and

strengthen the parent–child relationship (Marcus & Breton,

2013). Each professional brings their valuable expertise to the

team, but the focus must remain on the child and caregiver,

to provide family-focused care in a collaborative treatment

approach because of the complex and multi-contextual nature

of PFDs.

OCCUPATIONAL THERAPY’S ROLE IN PEDIATRIC FEEDING

Occupational therapy practitioners (OTPs) are specifically

trained to enable and increase participation in ADLs, including

feeding, eating, and swallowing (AOTA, 2017b). Furthermore,

OTPs “have the education, knowledge, and skills necessary for

the evaluation of and intervention with feeding, eating, and

swallowing problems” (AOTA, 2017b, p. 1). The lifespan focus

of occupational therapy enables practitioners to provide care to

the youngest of patients and their caregivers, starting at breast

and/or bottle feedings. As an infant grows, the OT’s extensive

knowledge of developmental milestones allows them to aid in

the transition to complementary and solid foods and liquids

when appropriate (AOTA, 2017b).

If a child is suspected of having difficulty swallowing or

aspirating, a modified barium swallow study (MBSS), also

referred to as a videofluroscopic swallow study (VFSS), may be

ordered. An MBSS/VFSS examines the “physiological function

of the swallowing mechanism” (Martin-Harris et al., 2020, p.

1079). During the swallow study examination, a child consumes

solids and liquids of varying consistencies coated or mixed

with barium sulfate for contrast while imaging. As a result,

physicians and feeding therapists are able to visualize swallow-

ing physiology to determine adequate function. The swallow

study is able to reveal lip closure, chewing (mastication), bolus

propulsion, tongue and epiglottis movement, and the path of

liquids and solids from the oral cavity to the esophagus—or in

the case of aspiration, to the larynx (Martin-Harris et al., 2020).

While working in an interprofessional team, both OTs and SLPs

with proper training can perform portions of this test (Paul &

D’Amico, 2013).

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Occupational therapy practioners are well equipped to pro-

vide care to pediatric patients and their caregivers at any point

in the therapeutic process. According to AOTA (2017b), “Practi-

tioners develop clinical reasoning skills to consider the interplay

of physical, cognitive, emotional, environmental, and sociocul-

tural factors in providing effective services for feeding, eating,

and swallowing dysfunction” (p. 2). The multi-contextual nature

of PFDs emphasizes the strength OTs possess to incorporate the

aforementioned factors into treatment. Furthermore, this client-

and family-centered practice requires practitioners to provide

care not only to the child, but also to the caregiver, specifically

in relation to the resulting stress from a child with a PFD.

In a study conducted to understand the effect of PFDs on

caregivers and daily activities, including social participation,

the researchers concluded that family-centered and occupa-

tion-based treatments improve the overall QoL for both the

child and their families (Simione et al., 2020). This further

supports the vital role Occupational therapy practioners have in

treating and educating caregiver(s) and children with feeding

disorders (Paul & D’Amico, 2013).

Incorporating meaningful and occupation-based treatments

is an important part of the OT’s role in caring for children

with feeding disorders. OTs work to create safe, functional

feeding habits and routines to increase the child’s ability to

participate in mealtimes. In a systematic review conducted

by Howe and Wang (2013), interventions commonly imple-

mented by OTs include behavioral, parent-directed and

educational, and physiological. Children receiving behavioral

interventions (e.g., differential attention, shaping, fading,

escape extinction) increased food variety, mealtime behaviors,

and self-feeding skills. Studies reviewing the effectiveness of

education and relationship-based interventions (i.e., providing

caregivers with information and recommendations relating to

their child’s feeding difficulties) produced improvements in a

child’s physical growth and development, as well as child and

caregiver feeding competence.

Physiological interventions focused on the complexity of

the developmentally acquired actions necessary for successful

feeding: breathing, sucking, and swallowing. Interventions for

this approach included preparatory behaviors (e.g., nonnu-

tritive sucking, skin-to-skin contact), feeding skills (e.g., oral

stimulation to elicit sucking and swallowing), and environ-

mental supports (e.g., positioning devices and modified equip-

ment such as a slow-flow nipple) (Howe & Wang, 2013).

The OT is also responsible for assessing and treating oral-sen-

sory issues. Occupational therapy’s unique understanding of the

sensory system allows for developing strategies to increase the

acceptance of food textures (Feeding Matters, n.d.). Occupa-

tional therapy’s educational background equips practitioners

with the tools necessary to treat such conditions, including

“neuroscience, anatomy, and activity/environmental analysis

to identify and treat occupational performance issues result-

ing from sensory modulation, sensory integration, motor, and

psychosocial deficits” (AOTA, 2017a, p. 2). The Sequential Oral

Sensory approach to feeding is an example of an evidence-based

intervention that supports children’s exploration of food

through play, which leads to an increase in food acceptance

(Toomey & Ross, 2013).

Occupational therapy’s scope of practice includes knowledge

on the use of low- and high-tech assistive devices (AOTA,

2015). An assistive technology device is defined under the

Individuals with Disabilities Act of 1988 as “any item, piece

of equipment, or product system, whether acquired commer-

cially off the shelf, modified, or customized, that is used to

increase, maintain, or improve functional capabilities of indi-

viduals with disabilities” (AOTA, 2010, p. S46). Due to man-

ifestation of CP, marked by a lack of volitional control over

movements, positional devices are used to improve physical

stabilization of the child, particularly by providing support for

optimal alignment at key points of control, including the feet,

knees, hips, trunk, and head (Hulme et al., 1987; Lino et al.,

2020). Positional devices, also referred to as adaptive seating

devices, maintain head and trunk in an upright, vertical plane.

Position hips at greater than 90° of flexion to prevent posterior

pelvic tilt and pelvic thrust.

An example of an assistive device includes placing a small

towel under a child’s knees to increase the hip flexion (Hurley,

2012). Below the waist, positional devices maintain knees in 90°

of flexion and ankles in neutral, and support bilateral feet place-

ment (Hulme et al., 1987). Using positional devices for chil-

dren with spastic, hypotonic, or mixed tone not only improved

sitting posture, but also increased the ability to maintain food in

the oral cavity and consume foods of enlarged texture (puree/

blended to chopped/cut up) (Hulme et al., 1987).

Adaptive equipment (AE) frequently prescribed by OTs for

clients with CP is found to improve participation in daily life

activities, including components of feeding such as using a cup

or cutlery (Lino et al., 2020). Adaptive feeding equipment may

include cups with lids and straws of differing sizes, heights, and

materials. Lino and colleagues (2020) concluded that using such

adaptive cups increases independence in task completion, as

the equipment enables a child with CP who has limited upper

extremity control to drink independently.

AE to improve using cutlery improved independence in

the task. Equipment used during interventions included

angled-handled spoons, neoprene orthoses, and foam-grip

tubing (Lino et al., 2020). Overall, positional devices and AE

may be used alone or in combination to increase muscle tone,

posture, trunk control, fine motor skills, and coordination

(Feeding Matters, n.d.).

ASSESSMENT

The most difficult part of the assessment process is evalu-

ating oral motor skills and swallowing function. To date, there

is not a comprehensive feeding and swallowing standardized

assessment that includes all the complex areas of feeding, espe-

cially oral motor skills (Korth & Maune, 2020). Considering the

phases of swallow and the four domains of PFDs is one system-

atic approach to observing and evaluating the process of eating

and swallowing.

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PHASES OF SWALLOW

Swallowing is defined by the three phases of swallow: oral,

pharyngeal, and esophageal (Marcus & Brenton, 2013; Ross,

2012; VitalStim Therapy, 2015). In some literature, the oral

phase is divided into two: an anticipatory or oral prep phase,

and an oral phase (Korth & Maune, 2020). Another way to view

the phases of swallow is through the voluntary phases (antic-

ipatory and oral) and the involuntary phases (pharyngeal and

esophageal) (DINES, 2019). Each phase of swallow has a neural

component, resulting in the high prevalence of children with CP

with dysphagia (Bashar et al., 2015).

In the anticipatory, or oral prep phase, the sensory

variables of the environment are considered, the food is

introduced, the lips close, and a bolus is formed. Phase one

intervention considerations for the OT include evaluating

hunger, the environment, positioning, hand-to-mouth coordi-

nation, size of the bite, sensory concerns, AE, and behaviors;

as well as improving the quality of chewing through improved

oral motor skills of the lips, jaw, cheeks, and tongue. Approx-

imately 80% of parents of children with CP report their child

as having difficulty with chewing, and these children often

have difficulty with the transition to solid food (Aggarwal et

al., 2015).

Regardless of whether a child has a disability, children who

do not properly master oral motor milestones will have diffi-

culty chewing and are at an increased risk for negative feeding

experiences. Children under the age of 4 years are still devel-

oping the correct oral motor patterns and coordination needed

to safely and correctly chew typical foods. In addition, chewing

is considered a learned behavior (Brackett, 2016). A child first

learns to suck on a nipple to receive food; if a child is given solid

food too early, they will simply just suck on the solid food. A

child must be taught to chew and practice these skills. Without

proper practice, a child is not able to properly break down the

food, increasing their risk of choking.

For children with CP, maintaining proper positioning can

also be problematic. Swallowing muscles work best in their

neutral position, and poor posture can lead to decreased tone.

The child should be properly positioned with hips, knees, and

ankles at 90°, and head and neck in neutral to facilitate optimal

conditions. An example of the dangers of poor position is neck

hyperextension, which increases the risk of aspiration (Aggarwal

et al., 2015). Another important factor is the internal motivation

of the child; the food must be appealing for the child to success-

fully engage in the task (DINES, 2019).

Phase two is the oral phase, which is also under voluntary

control, and is marked by the bolus propulsion into the pharynx

by the tongue lifting against the hard palate (Korth & Rendell,

2015). Phase two interventions all target oral motor skills, such

as tongue movements for retraction and lateralization and

cheek strength (buccinators) to keep the food on the teeth and

eliminate pocketing (narrowing of the cavity creates positive

pressure).

Another key factor is making sure the mouth is closed. Lip

closure is often a problem for children with severe disabil-

ities and decreases the force of the bolus propulsion. “Lip

seal, which is also a component of lip closure, is a predictor

of drooling,” which is also an area of concern for approxi-

mately 40% of children with CP (Reid et al., 2012, p. 1035).

Strengthening the orbicularis and buccinator muscles will

improve lip closure, as they act as a sling with the upper

pharyngeal constrictor to create the positive pressure needed

for bolus propulsion (VitalStim Therapy, 2015). The tongue

must also have the appropriate range of motion and strength

to push against the posterior pharyngeal wall with enough

power to create the positive pressure needed for bolus pro-

pulsion. Observations of the oral phases include watching to

ensure there is no spillage, pocketing, or nasal regurgitation,

with the bolus propelled successfully in a single swallow

(VitalStim Therapy, 2015).

Phase three is the pharyngeal phase, which begins the

involuntary phases of swallow. Phase three begins with the

initial swallow followed by hyolaryngeal excursion; the phase

ends with the opening of the upper esophageal sphincter (UES)

(Korth & Rendell, 2015). OTs must observe for signs and symp-

toms of aspiration, which can occur during this phase. VFSSs

have indicated that children with CP have “pulmonary aspi-

ration in 38% to over 70% of the cases” (Erasmus et al., 2012,

p. 412). A slow-moving bolus, which is a pressure-generation

problem, can increases the risk of aspiration (DINES, 2019). The

“longer it takes for the swallowing reflex to trigger, the greater

the chance of aspirating food, as the airway remains open and

unprotected” (Lagos-Guimarães et al., 2016, p. 136).

In addition to a VFSS, which is the most recommended

assessment for aspiration in children (Lagos-Guimarães et al.,

2016), therapists can take several objective measures to deter-

mine whether aspiration is occurring, such as using a pulse

oximeter to monitor oxygen saturation (Smith et al., 2000),

taking temperatures (Karagiannis et al., 2011), and performing

cervical auscultation (Frakking et al., 2019). Although none

of these alternative measures is a standalone assessment, they

offer critical information that may assist other observations,

such as coughing, watery eyes, and irritability during mealtimes.

Observations of coughing is critical, as this is always indicative

that a child is in distress (DINES, 2019). Children under 3

years and children with CP are at an increased risk for choking

during mealtimes. Using the fingernail of the child’s fifth digit

as a guide to bite size is recommended to help reduce choking

(Cichero et al., 2017).

The fourth phase of swallow is the esophageal phase, which

begins and ends with the bolus entering the UES (also known as

the pharyngoesophageal sphincter in adult practice) and leaving

through the lower esophageal sphincter (LES). The opening of

the UES relies on the movement sensation of the hyolaryngeal

excursion and the pharyngeal shortening (DINES, 2019). Both

of these motor movements are involuntary with a neurological

component; therefore, opening the UES can be problematic for

children with neurological disorders. Gastroesophageal reflux

(GER) occurs with unwanted opening or relaxation of the LES.

GER is estimated to occur in approximately half of children

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with CP (Erasmus et al., 2012). Although some researchers have

reported the prevalence to be as high as 77% in children with

CP, contributing factors include the frequency of supine posi-

tioning and scoliosis, which can cause the LES to stretch (Fer-

nando & Goldman, 2019). It is important to note that scoliosis

can worsen during puberty, and therefore dysphagia symptoms

can also worsen (Arvedson, 2013).

Many children with CP also have an elevated rib cage, shal-

low breathing, and an increased respiratory rate (Stamer, 2016).

The clinician should always observe the child eating in the

natural environment, and in as many environments as possible.

Consider the school cafeteria seating or the lack of a feeding

chair in many homes. The child’s posture may be negatively

affecting breathing and the ability to successfully self-feed and/

or swallow. In the school setting, a child with CP sometimes may

not be communicating at lunch with peers because of the effort

required to eat, or conversely, may not be eating because of the

effort needed to communicate.

Nutritional concerns for children with CP have been reported

to be as high as 90% (Inal et al., 2017). Because nutritional rec-

ommendations, such as supplements, are not within the occu-

pational therapy scope of practice, it is critical to refer to other

professionals when necessary. A new four-question Feeding and

Nutrition Screening Tool for Cerebral Palsy, developed by Bell and

colleagues (2019), is freely available for occupational therapy

practitioners and other professionals to use. This tool results in a

score indicating whether to refer for other services.

Education on safe foods for a child to eat needs to match

their skill level (versus their chronological age) and is one of

the most important steps in the evaluation process. If the child

needs a modified diet or thickened liquids for a safe swallow,

consulting a physician and the registered dietician is recom-

mended. The new International Dysphagia Diet Standardiza-

tion Initiative provides a universal definition for consistency

of liquids and food textures on one continuous scale (Cichero

et al., 2017). This is critical for the child transitioning between

environments.

Psychosocial factors is another domain within the PFD’s

definition, and it refers to both the child and the caregiver

(Goday et al., 2019). When a child has a PFD, there may be a

disruption in the bonding process between child and caregiver,

which is why “many researchers view feeding disorders as a

relationship disorder” (Didehbani et al., 2011, p. 86). Insecure

attachment and difficulty bonding are concerns for children

with CP, because of the child’s limited abilities to communi-

cate their needs to the caregiver (Barthel et al., 2016).

Given that the prevalence of feeding difficulties in children

with CP can range as high as 100% depending on the classifi-

cation system (Lagos-Guimarães et al., 2016), clinicians need

to include psychosocial concerns in their evaluation process.

Although not yet widely used across all practice settings,

including a maternal mental health screen as part of the

evaluation process is recommended as best practice (Sepul-

veda et al., 2020). Free maternal mental health screens are

available online, such as the Edinburgh Postnatal Depression

Scale (https://psychology-tools.com/epds/) and the Postpartum

Social Support Screening Tool (https://artemisguidance.com/

pssst/). Treating the child–caregiver dyad, especially when

focusing on feeding difficulties, can result in improved out-

comes when both the child and caregiver are engaged (Barlow

& Sepulveda, 2020; Sepulveda, 2019).

Feeding difficulties can impair social relationships, not only

between the caregiver and child, but also between peers as

children age. As mentioned previously, in the school cafeteria

the child with CP may be sitting unsupported at a table. Proper

positioning is critical not only for optimal swallowing results,

but also for facilitating positive behaviors and communication

with caregivers and peers (Bashar et al., 2015). One of the oral

motor deficit areas that affects the child’s ability to make friends

is drooling. Drooling occurs in up to 58% of children with CP

and can have a negative effect on a child’s mental health and

peer interactions (Erasmus et al., 2012).

The final domain to consider in the evaluation of PFDs is the

child’s feeding skills, which include not only the oral motor skills

necessary for a safe swallow, but also sensory functions, posture,

and hand-to-mouth coordination. Children with CP do not

always mouth toys like typically developing children do, delaying

the gag reflex from moving to the posterior third of the tongue,

as well as delaying tongue lateralization. The delayed integration

of reflexes affects a child’s motor skills, social skills, and feeding

skills.

It is also critical to consider the amount of time a child takes

to eat, and the energy spent when a child is eating. If mealtimes

are limited to 20 minutes in a school environment, clinicians

need to consider how many calories the child was able to

consume versus expend. When children take longer than 30

minutes to eat a meal—referred to as inefficient oral feeding—a

modified diet or consultation to a nutritionist should be consid-

ered (Goday et al., 2019).

For assessing dysphagia in preschool children with CP, the

Schedule Oral Motor Assessment and the Dysphagia Disorders

Survey have been recognized as having the “strongest clinical

utility to support clinical decision-making” (Benfer et al., 2012,

p. 794). The Rehabilitation Guideline for the Management of Chil-

dren With CP recommends that OTs use the Eating and Drinking

Ability Classification System (www.EDACS.org), which was

developed for children with CP ages 3 years and older (Human-

ity & Inclusion, 2018). A survey of more than 450 pediatric

feeding therapists (OTs and SLPs), however, found that most

clinicians used a non-standardized assessment tool to evaluate

feeding skills, followed by VFSSs and the Beckman Oral Motor

Protocol (Barlow & Rabaey, 2020). Feedingflock.com provides

clinicians with several free assessment tools, such as the Child

Oral and Motor Proficiency Scale, Family Management Measure

of Feeding, and the Pediatric Eating Assessment Tool. Feeding

Matters also has a free screening tool available on its website

(https://questionnaire.feedingmatters.org/questionnaire).

Regardless of which assessment tool you choose, it is important

that all domains of a PFD are considered and evaluated when

appropriate.

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TREATMENT

A good assessment is the key to successful treatment. It is not

possible to cover every treatment scenario, but consider a few

key points. An open mouth posture is prevalent in 93% of

children with CP (Inal et al., 2017). Training for straw drinking

can begin at 6 months (Bahr, 2010); this is critical, as research

has shown approximately 80% of children with CP who can use

a straw do not drool (Reid et al., 2012). In addition to drooling,

oral motor exercises have been shown effective in improving

tongue lateralization, lip closure, and swallowing evaluation

results (Siğan et al., 2013).

Understanding the phases of swallow, and what is occurring

in each phase, should guide your clinical reasoning as to why

your client is having swallowing difficulty. Given that children

with CP often have decreased strength of their oral motor mus-

culature, and that swallowing muscles are mostly type II muscle

fibers, interventions must be focused on increasing workload to

increase strength. Therapeutic interventions must be consis-

tently challenging, such as with increased resistance, to activate

the type II muscle fibers. Repeating the same exercises 10 times

each session for 6 weeks will not activate type II fibers, only

type I. Neuromuscular electrical stimulation (NMES) activates

type II muscle fibers first and is a great therapeutic tool for

increasing the strength of swallowing muscles for children with

CP (Song et al., 2015).

Free continuing education webinars on treating oral motor

skills are available on several websites, including Therapro

(www.therapro.com/Information-Items/Webinars/), Ages and

Stages (www.agesandstages.net/courses.php), and OT OER

(https://libguides.aic.edu/OT_OER/webinars). Beckman Oral

Motor (www.beckmanoralmotor.com/) and Talk Tools (https://

talktools.com/) have continuing education courses that focus on

oral motor skills, and are highly recommended.

EVALUATION

A team approach is always recommended for a feeding eval-

uation; however, for a child with CP, this is especially true.

Respiratory concerns, along with vision, sensory, cardiopul-

monary, nutritional, and digestive factors, should be consid-

ered in the evaluation process (Stamer, 2016). Depending

on the age of the child and individual interactions, the

various environments also need to be considered, such as

day care, school, and home settings. The complexity of the

feeding evaluation for a child with CP lends itself to the team

approach, given the expertise needed for a comprehensive

evaluation.

Examining the four domains of PFDs specific to CP, begin-

ning with the medical domain, is a recommended systematic

approach. For example, constipation and respiratory rate are

two common concerns. Constipation, due to neuromuscular

factors and decreased mobility, is common, with a prevalence of

26% to 74% in children with CP (Trivi & Hojsak, 2018). Asking

caregivers how often the child has a bowel movement and the

consistency of the stool can provide important clues in deter-

mining hunger, eating habits, and behavior.

CONCLUSION

Occupational therapy practioners are always focused on the

whole child and providing family-centered care. In treating CP,

the primary goal of intervention must be to improve the life of

the child and the family (Aggarwal et al., 2015). The complexity

of the feeding evaluation for the child with CP requires a com-

mitment to continued learning and involving the members of an

interdisciplinary team for optimal outcomes.

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are also available ONLINE.

call toll-free 877-404-AOTA (2682).

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Final Exam

Article Code CEA0321

Evaluation of Feeding, Eating, and Swallow-

ing for Children With Cerebral Palsy

To receive CE credit, exam must be completed by

March 31, 2024

Learning Level: Learning Level: Intermediate to advanced

Target Audience: Occupational Therapy Practitioners

Content Focus: Domain: Client Factors; OT Process: Occupational Therapy

Evaluation and Intervention

1. Which of the following phases of swallow is involuntary?

A. Oral prep phase

B. Anticipatory phase

C. Oral phase

D. Esophageal phase

2. In which of the following phases of swallow can aspiration

occur?

A. Oral prep phase

B. Oral phase

C. Pharyngeal phase

D. Esophageal phase

3. In which of the following phases of swallow can reflux occur?

A. Oral prep phase

B. Oral phase

C. Pharyngeal phase

D. Esophageal phase

4. Gastroesophageal reflux occurs:

A. During the unwanted opening or relaxation of the upper

esophageal sphincter

B. During the unwanted opening or relaxation of the lower

esophageal sphincter

C. When hyolaryngeal excursion is unsuccessful

D. When the pharyngeal shortening is unsuccessful

5. Which of the following is the most recommended assessment to

detect aspiration in children?

A. Videofluroscopic swallow study

B. Pulse oximeter to monitor oxygen saturation

C. Taking temperatures

D. Cervical auscultation

6. Which three muscles work together as the muscular sling

responsible for bolus propulsion?

A. Orbicularis, buccinators, and styloglossus

B. Orbicularis, buccinators, and upper pharyngeal

constrictor

C. Upper pharyngeal constrictor, styloglossus, and

geniohyoid

D. Geniohyoid, mylohyoid, and stylohyoid

7. Due to the known difficulties of attachment and bonding for

children and caregivers with feeding concerns, the occupational

therapist can include which of the following in their assessment?

A. The Feeding and Nutrition Screening Tool for Cerebral

Palsy

B. The Schedule Oral Motor Assessment

C. The Child Oral and Motor Proficiency Scale

D. Edinburgh Postnatal Depression Scale

How to Apply for

Continuing Education Credit

A. To get pricing information and to register to take the exam online for

the article Evaluation of Feeding, Eating, and Swallowing for Children With

Cerebral Palsy,

go to http://store.aota.org, or call toll-free 800-729-2682.

B. Once registered and payment received, you will receive instant email

confirmation.

C. Answer the questions to the final exam found on pages CE-8 & CE-9

March 31, 2024

D. On successful completion of the exam (a score of 75% or more), you will

immediately receive your printable certificate.

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Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-8 for details.

Continuing Education Article

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Now that you have selected your answers, you are

only one step away from earning your CE credit.

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8. Which of the following exercises has been shown to prevent

drooling?

A. Tongue lateralization exercises

B. Tongue range of motion exercises

C. Straw drinking

D. Jaw strengthening exercises

9. Which of the following is NOT true regarding the muscles

involved in swallowing?

A. Most muscles involved in swallow are Type I muscle

fibers.

B. Most muscles involved in swallow are Type II muscle

fibers.

C. Neuromuscular electrical stimulation targets Type II

muscle fibers first.

D. Exercises for swallow must consistently challenge the

patient with an increased workload.

10. Which of the following is NOT true regarding lip closure?

A. It predicts drooling

B. It creates positive pressure for bolus propulsion

C. It creates negative pressure for bolus propulsion

D. Oral motor exercises have been proven effective in the

treatment of lip closure

11. Which of the following is NOT true regarding the buccinator

muscle?

A. It narrows the oral cavity, creating positive pressure

B. It narrows the oral cavity, creating negative pressure

C. It is part of the muscular sling involved in bolus

propulsion

D. It keeps the food on the teeth while chewing

12. The gag reflex affects feeding in what way?

A. Its integration facilitates social interactions for speech

production

B. Its integration facilitates children chewing on toys for

tongue lateralization

C. Its integration facilitates children chewing on toys for lip

strength

D. Its integration facilitates bilateral hand coordination for

pacifier use

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