Continuing Education Article

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

Evaluation of Feeding, Eating, and

Swallowing for Children With Cerebral
Palsy
Kate Barlow, OT, OTD, OTR lead to a decreased perception of their quality of life (QoL) (Ede-
Assistant Professor of American International College mekong et al., 2020). When a child is born, they must rely on
Springfield, MA caregivers to complete basic ADLs; however, as they grow, chil-
dren learn to complete these tasks for themselves. The motivation
Kelsey Sullivan, OTS to do so is linked to an innate feeling of competence and satis-
Occupational therapy student at MGH Institute of Health Professions faction when successfully completed independently (Shepherd
Boston, MA & 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-
This CE Article was developed in collaboration with AOTA’s Children & Youth herd & Ivey, 2020).
Special Interest Section Children born with cerebral palsy (CP), the most com-
monly diagnosed motor disability in children, have “motor,
ABSTRACT cognitive, and perceptive impairments” that affect their ability
Most children with cerebral palsy (CP) also have a pediatric to complete many ADLs (Erasmus et al., 2012, p. 409). Of
feeding disorder (PFD). Evaluating feeding in children with CP is importance, several studies suggest that children with CP have
a highly complex process that is best done in a team environment. a particular difficulty in completing various tasks associated
This article describes the prevalence of PFDs in children with CP with feeding. Dysphagia, the impaired ability to swallow, is
and highlights the special clinical considerations of the occupa- prevalent in more than half of all children with CP and is the
tional therapist in evaluating PFDs in children with CP. “leading cause of death in individuals with CP” (Novak et al.,
2020, p. 10). Additionally, children with CP are chronically
LEARNING OBJECTIVES classified as malnourished for reasons that include oral motor
After reading this article, you should be able to: dysfunction, chewing disorders, and postural abnormalities
1. Identify the elements of PFDs resulting from CP that require (Inal et al., 2017).
special consideration The complexity of CP cases with comorbid conditions, par-
2. Identify the typical phases of swallowing and the impact of CP ticularly feeding disorders, requires a qualified team approach
3. Describe the role of the occupational therapist in assessing when evaluating and treating for various impairments during
each phase of swallow for children with CP. both volitional and reflexive phases of feeding and swallow-
ing. The purpose of this article is to highlight the prevalence
INTRODUCTION of feeding disorders in children with CP, and the role of the
Eating and swallowing are ADLs that individuals learn to master occupational therapist (OT) in evaluating children with CP
to independently function and take care of themselves (American who have feeding difficulties. Evidence-based evaluation and
Occupational Therapy Association [AOTA], 2020). Impairment in treatment considerations for this specific population will be
one’s ability to properly and safely complete necessary ADLs may reviewed.

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PREVALENCE OF CP IN THE UNITED STATES AND GLOBALLY When addressing the nutritional needs and potential dys-
CP is the most common pediatric motor disability in the United function of this area, a registered dietitian (RD) is often needed.
States, affecting approximately 2 per 1,000 live births, or An RD will assess whether a child is obtaining the necessary
around 10,000 births a year (Poinsett, 2020). Furthermore, it is calories, fluids, and other vital nutrients for optimal growth and
estimated that more than 750,000 children and adults have this functioning, as well as recommend a modified diet when appro-
motor disability. Globally, there are approximately 50 million priate (Marcus & Breton, 2013). This specialist has expertise
individuals living with CP who require rehabilitation services in creating a well rounded and tolerated diet for the child and
(Cieza et al., 2020). works collaboratively with SLPs and OTs for effective feeding
Although CP is the most commonly diagnosed motor skill development.
condition in children, its exact cause has not been identi- The role of OTs in pediatric feeding will be further discussed
fied (Cerebral Palsy Alliance, 2015). Research has identified in detail in the following section; however, they play a crucial
several risk factors associated with high rates of children with role, along with SLPs, in aiding a child with CP to properly
CP, including low birthweight and premature birth, multiple develop the necessary skills to feed successfully.
pregnancies, and maternal infection (Reidy et al., 2020). Last, psychosocial dysfunction may present not only in the
Additionally, higher rates of CP are diagnosed in males and child with a PFD, but also in the parents, caregivers, and family
non-Hispanic black children (Stavsky et al., 2017). A child members who tend to the child. A psychologist or psychiatrist
with CP is diagnosed according to one of four main types, may evaluate the child and caregivers’ mealtime behaviors to
including spastic (80% to 86% of cases), dyskinetic, ataxic, or identify strategies to increase positive feeding experiences and
mixed (Stamer, 2016). Hallmark symptoms depend on type, strengthen the parent–child relationship (Marcus & Breton,
but they commonly include reduced gross motor skills, poor 2013). Each professional brings their valuable expertise to the
postural control, and abnormal muscle tone, which all affect team, but the focus must remain on the child and caregiver,
function (Labaf et al., 2015). to provide family-focused care in a collaborative treatment
Although not considered hallmark features of the con- approach because of the complex and multi-contextual nature
dition, feeding difficulties affect 70% to 80% of children of PFDs.
with CP (Korth & Rendell, 2015). Additionally, drooling and
swallowing difficulties were estimated to affect 44% and 50% OCCUPATIONAL THERAPY’S ROLE IN PEDIATRIC FEEDING
of individuals with CP, respectively. Individuals with more Occupational therapy practitioners (OTPs) are specifically
severe forms of CP and increased impairment in functioning trained to enable and increase participation in ADLs, including
were found to have a higher prevalence of feeding problems. feeding, eating, and swallowing (AOTA, 2017b). Furthermore,
Furthermore, those who had difficulties with feeding showed OTPs “have the education, knowledge, and skills necessary for
increased rates of malnutrition and aspiration pneumonia, and the evaluation of and intervention with feeding, eating, and
an overall decrease in QoL. swallowing problems” (AOTA, 2017b, p. 1). The lifespan focus
of occupational therapy enables practitioners to provide care to
PEDIATRIC FEEDING DISORDERS the youngest of patients and their caregivers, starting at breast
Pediatric feeding disorders (PFDs) affect up to 29% of all children and/or bottle feedings. As an infant grows, the OT’s extensive
in the United States (Silverman et al., 2020). Despite the preva- knowledge of developmental milestones allows them to aid in
lence of such conditions, there is a lack of awareness and univer- the transition to complementary and solid foods and liquids
sally accepted definition for PFDs. With influence from the World when appropriate (AOTA, 2017b).
Health Organization’s International Classification of Functioning, If a child is suspected of having difficulty swallowing or
Disability and Health, the following definition is proposed: PFDs aspirating, a modified barium swallow study (MBSS), also
are “impaired oral intake that is not age appropriate and associ- referred to as a videofluroscopic swallow study (VFSS), may be
ated with medical, nutritional, feeding skill, and/or psychosocial ordered. An MBSS/VFSS examines the “physiological function
dysfunction” (Goday et al., 2019, p. 124). With this definition in of the swallowing mechanism” (Martin-Harris et al., 2020, p.
mind, PFDs are clearly complex in nature and require a holistic 1079). During the swallow study examination, a child consumes
and collaborative approach to evaluation and treatment. solids and liquids of varying consistencies coated or mixed
PFDs may encompass one or more impairments within the with barium sulfate for contrast while imaging. As a result,
domains of medical, nutritional, feeding skills, and/or psy- physicians and feeding therapists are able to visualize swallow-
chosocial dysfunction, thus requiring the child’s physician to ing physiology to determine adequate function. The swallow
obtain further information from a range of medical specialists, study is able to reveal lip closure, chewing (mastication), bolus
including, but not limited to, an allergist, dentist, gastroenter- propulsion, tongue and epiglottis movement, and the path of
ologist, dietician, psychologist, speech-language pathologist liquids and solids from the oral cavity to the esophagus—or in
(SLP), and OT (Marcus & Breton, 2013). These specialists aid the case of aspiration, to the larynx (Martin-Harris et al., 2020).
in the comprehensive evaluation process and perform tests to While working in an interprofessional team, both OTs and SLPs
assess feeding and swallowing ability, along with the potential with proper training can perform portions of this test (Paul &
for comorbid conditions. D’Amico, 2013).

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Occupational therapy practioners are well equipped to pro- intervention that supports children’s exploration of food
vide care to pediatric patients and their caregivers at any point through play, which leads to an increase in food acceptance
in the therapeutic process. According to AOTA (2017b), “Practi- (Toomey & Ross, 2013).
tioners develop clinical reasoning skills to consider the interplay Occupational therapy’s scope of practice includes knowledge
of physical, cognitive, emotional, environmental, and sociocul- on the use of low- and high-tech assistive devices (AOTA,
tural factors in providing effective services for feeding, eating, 2015). An assistive technology device is defined under the
and swallowing dysfunction” (p. 2). The multi-contextual nature Individuals with Disabilities Act of 1988 as “any item, piece
of PFDs emphasizes the strength OTs possess to incorporate the of equipment, or product system, whether acquired commer-
aforementioned factors into treatment. Furthermore, this client- cially off the shelf, modified, or customized, that is used to
and family-centered practice requires practitioners to provide increase, maintain, or improve functional capabilities of indi-
care not only to the child, but also to the caregiver, specifically viduals with disabilities” (AOTA, 2010, p. S46). Due to man-
in relation to the resulting stress from a child with a PFD. ifestation of CP, marked by a lack of volitional control over
In a study conducted to understand the effect of PFDs on movements, positional devices are used to improve physical
caregivers and daily activities, including social participation, stabilization of the child, particularly by providing support for
the researchers concluded that family-centered and occupa- optimal alignment at key points of control, including the feet,
tion-based treatments improve the overall QoL for both the knees, hips, trunk, and head (Hulme et al., 1987; Lino et al.,
child and their families (Simione et al., 2020). This further 2020). Positional devices, also referred to as adaptive seating
supports the vital role Occupational therapy practioners have in devices, maintain head and trunk in an upright, vertical plane.
treating and educating caregiver(s) and children with feeding Position hips at greater than 90° of flexion to prevent posterior
disorders (Paul & D’Amico, 2013). pelvic tilt and pelvic thrust.
Incorporating meaningful and occupation-based treatments An example of an assistive device includes placing a small
is an important part of the OT’s role in caring for children towel under a child’s knees to increase the hip flexion (Hurley,
with feeding disorders. OTs work to create safe, functional 2012). Below the waist, positional devices maintain knees in 90°
feeding habits and routines to increase the child’s ability to of flexion and ankles in neutral, and support bilateral feet place-
participate in mealtimes. In a systematic review conducted ment (Hulme et al., 1987). Using positional devices for chil-
by Howe and Wang (2013), interventions commonly imple- dren with spastic, hypotonic, or mixed tone not only improved
mented by OTs include behavioral, parent-directed and sitting posture, but also increased the ability to maintain food in
educational, and physiological. Children receiving behavioral the oral cavity and consume foods of enlarged texture (puree/
interventions (e.g., differential attention, shaping, fading, blended to chopped/cut up) (Hulme et al., 1987).
escape extinction) increased food variety, mealtime behaviors, Adaptive equipment (AE) frequently prescribed by OTs for
and self-feeding skills. Studies reviewing the effectiveness of clients with CP is found to improve participation in daily life
education and relationship-based interventions (i.e., providing activities, including components of feeding such as using a cup
caregivers with information and recommendations relating to or cutlery (Lino et al., 2020). Adaptive feeding equipment may
their child’s feeding difficulties) produced improvements in a include cups with lids and straws of differing sizes, heights, and
child’s physical growth and development, as well as child and materials. Lino and colleagues (2020) concluded that using such
caregiver feeding competence. adaptive cups increases independence in task completion, as
Physiological interventions focused on the complexity of the equipment enables a child with CP who has limited upper
the developmentally acquired actions necessary for successful extremity control to drink independently.
feeding: breathing, sucking, and swallowing. Interventions for AE to improve using cutlery improved independence in
this approach included preparatory behaviors (e.g., nonnu- the task. Equipment used during interventions included
tritive sucking, skin-to-skin contact), feeding skills (e.g., oral angled-handled spoons, neoprene orthoses, and foam-grip
stimulation to elicit sucking and swallowing), and environ- tubing (Lino et al., 2020). Overall, positional devices and AE
mental supports (e.g., positioning devices and modified equip- may be used alone or in combination to increase muscle tone,
ment such as a slow-flow nipple) (Howe & Wang, 2013). posture, trunk control, fine motor skills, and coordination
The OT is also responsible for assessing and treating oral-sen- (Feeding Matters, n.d.).
sory issues. Occupational therapy’s unique understanding of the
sensory system allows for developing strategies to increase the ASSESSMENT
acceptance of food textures (Feeding Matters, n.d.). Occupa- The most difficult part of the assessment process is evalu-
tional therapy’s educational background equips practitioners ating oral motor skills and swallowing function. To date, there
with the tools necessary to treat such conditions, including is not a comprehensive feeding and swallowing standardized
“neuroscience, anatomy, and activity/environmental analysis assessment that includes all the complex areas of feeding, espe-
to identify and treat occupational performance issues result- cially oral motor skills (Korth & Maune, 2020). Considering the
ing from sensory modulation, sensory integration, motor, and phases of swallow and the four domains of PFDs is one system-
psychosocial deficits” (AOTA, 2017a, p. 2). The Sequential Oral atic approach to observing and evaluating the process of eating
Sensory approach to feeding is an example of an evidence-based and swallowing.

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PHASES OF SWALLOW ities and decreases the force of the bolus propulsion. “Lip
Swallowing is defined by the three phases of swallow: oral, seal, which is also a component of lip closure, is a predictor
pharyngeal, and esophageal (Marcus & Brenton, 2013; Ross, of drooling,” which is also an area of concern for approxi-
2012; VitalStim Therapy, 2015). In some literature, the oral mately 40% of children with CP (Reid et al., 2012, p. 1035).
phase is divided into two: an anticipatory or oral prep phase, Strengthening the orbicularis and buccinator muscles will
and an oral phase (Korth & Maune, 2020). Another way to view improve lip closure, as they act as a sling with the upper
the phases of swallow is through the voluntary phases (antic- pharyngeal constrictor to create the positive pressure needed
ipatory and oral) and the involuntary phases (pharyngeal and for bolus propulsion (VitalStim Therapy, 2015). The tongue
esophageal) (DINES, 2019). Each phase of swallow has a neural must also have the appropriate range of motion and strength
component, resulting in the high prevalence of children with CP to push against the posterior pharyngeal wall with enough
with dysphagia (Bashar et al., 2015). power to create the positive pressure needed for bolus pro-
In the anticipatory, or oral prep phase, the sensory pulsion. Observations of the oral phases include watching to
variables of the environment are considered, the food is ensure there is no spillage, pocketing, or nasal regurgitation,
introduced, the lips close, and a bolus is formed. Phase one with the bolus propelled successfully in a single swallow
intervention considerations for the OT include evaluating (VitalStim Therapy, 2015).
hunger, the environment, positioning, hand-to-mouth coordi- Phase three is the pharyngeal phase, which begins the
nation, size of the bite, sensory concerns, AE, and behaviors; involuntary phases of swallow. Phase three begins with the
as well as improving the quality of chewing through improved initial swallow followed by hyolaryngeal excursion; the phase
oral motor skills of the lips, jaw, cheeks, and tongue. Approx- ends with the opening of the upper esophageal sphincter (UES)
imately 80% of parents of children with CP report their child (Korth & Rendell, 2015). OTs must observe for signs and symp-
as having difficulty with chewing, and these children often toms of aspiration, which can occur during this phase. VFSSs
have difficulty with the transition to solid food (Aggarwal et have indicated that children with CP have “pulmonary aspi-
al., 2015). ration in 38% to over 70% of the cases” (Erasmus et al., 2012,
Regardless of whether a child has a disability, children who p. 412). A slow-moving bolus, which is a pressure-generation
do not properly master oral motor milestones will have diffi- problem, can increases the risk of aspiration (DINES, 2019). The
culty chewing and are at an increased risk for negative feeding “longer it takes for the swallowing reflex to trigger, the greater
experiences. Children under the age of 4 years are still devel- the chance of aspirating food, as the airway remains open and
oping the correct oral motor patterns and coordination needed unprotected” (Lagos-Guimarães et al., 2016, p. 136).
to safely and correctly chew typical foods. In addition, chewing In addition to a VFSS, which is the most recommended
is considered a learned behavior (Brackett, 2016). A child first assessment for aspiration in children (Lagos-Guimarães et al.,
learns to suck on a nipple to receive food; if a child is given solid 2016), therapists can take several objective measures to deter-
food too early, they will simply just suck on the solid food. A mine whether aspiration is occurring, such as using a pulse
child must be taught to chew and practice these skills. Without oximeter to monitor oxygen saturation (Smith et al., 2000),
proper practice, a child is not able to properly break down the taking temperatures (Karagiannis et al., 2011), and performing
food, increasing their risk of choking. cervical auscultation (Frakking et al., 2019). Although none
For children with CP, maintaining proper positioning can of these alternative measures is a standalone assessment, they
also be problematic. Swallowing muscles work best in their offer critical information that may assist other observations,
neutral position, and poor posture can lead to decreased tone. such as coughing, watery eyes, and irritability during mealtimes.
The child should be properly positioned with hips, knees, and Observations of coughing is critical, as this is always indicative
ankles at 90°, and head and neck in neutral to facilitate optimal that a child is in distress (DINES, 2019). Children under 3
conditions. An example of the dangers of poor position is neck years and children with CP are at an increased risk for choking
hyperextension, which increases the risk of aspiration (Aggarwal during mealtimes. Using the fingernail of the child’s fifth digit
et al., 2015). Another important factor is the internal motivation as a guide to bite size is recommended to help reduce choking
of the child; the food must be appealing for the child to success- (Cichero et al., 2017).
fully engage in the task (DINES, 2019). The fourth phase of swallow is the esophageal phase, which
Phase two is the oral phase, which is also under voluntary begins and ends with the bolus entering the UES (also known as
control, and is marked by the bolus propulsion into the pharynx the pharyngoesophageal sphincter in adult practice) and leaving
by the tongue lifting against the hard palate (Korth & Rendell, through the lower esophageal sphincter (LES). The opening of
2015). Phase two interventions all target oral motor skills, such the UES relies on the movement sensation of the hyolaryngeal
as tongue movements for retraction and lateralization and excursion and the pharyngeal shortening (DINES, 2019). Both
cheek strength (buccinators) to keep the food on the teeth and of these motor movements are involuntary with a neurological
eliminate pocketing (narrowing of the cavity creates positive component; therefore, opening the UES can be problematic for
pressure). children with neurological disorders. Gastroesophageal reflux
Another key factor is making sure the mouth is closed. Lip (GER) occurs with unwanted opening or relaxation of the LES.
closure is often a problem for children with severe disabil- GER is estimated to occur in approximately half of children

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with CP (Erasmus et al., 2012). Although some researchers have Scale (https://psychology-tools.com/epds/) and the Postpartum
reported the prevalence to be as high as 77% in children with Social Support Screening Tool (https://artemisguidance.com/
CP, contributing factors include the frequency of supine posi- pssst/). Treating the child–caregiver dyad, especially when
tioning and scoliosis, which can cause the LES to stretch (Fer- focusing on feeding difficulties, can result in improved out-
nando & Goldman, 2019). It is important to note that scoliosis comes when both the child and caregiver are engaged (Barlow
can worsen during puberty, and therefore dysphagia symptoms & Sepulveda, 2020; Sepulveda, 2019).
can also worsen (Arvedson, 2013). Feeding difficulties can impair social relationships, not only
Many children with CP also have an elevated rib cage, shal- between the caregiver and child, but also between peers as
low breathing, and an increased respiratory rate (Stamer, 2016). children age. As mentioned previously, in the school cafeteria
The clinician should always observe the child eating in the the child with CP may be sitting unsupported at a table. Proper
natural environment, and in as many environments as possible. positioning is critical not only for optimal swallowing results,
Consider the school cafeteria seating or the lack of a feeding but also for facilitating positive behaviors and communication
chair in many homes. The child’s posture may be negatively with caregivers and peers (Bashar et al., 2015). One of the oral
affecting breathing and the ability to successfully self-feed and/ motor deficit areas that affects the child’s ability to make friends
or swallow. In the school setting, a child with CP sometimes may is drooling. Drooling occurs in up to 58% of children with CP
not be communicating at lunch with peers because of the effort and can have a negative effect on a child’s mental health and
required to eat, or conversely, may not be eating because of the peer interactions (Erasmus et al., 2012).
effort needed to communicate. The final domain to consider in the evaluation of PFDs is the
Nutritional concerns for children with CP have been reported child’s feeding skills, which include not only the oral motor skills
to be as high as 90% (Inal et al., 2017). Because nutritional rec- necessary for a safe swallow, but also sensory functions, posture,
ommendations, such as supplements, are not within the occu- and hand-to-mouth coordination. Children with CP do not
pational therapy scope of practice, it is critical to refer to other always mouth toys like typically developing children do, delaying
professionals when necessary. A new four-question Feeding and the gag reflex from moving to the posterior third of the tongue,
Nutrition Screening Tool for Cerebral Palsy, developed by Bell and as well as delaying tongue lateralization. The delayed integration
colleagues (2019), is freely available for occupational therapy of reflexes affects a child’s motor skills, social skills, and feeding
practitioners and other professionals to use. This tool results in a skills.
score indicating whether to refer for other services. It is also critical to consider the amount of time a child takes
Education on safe foods for a child to eat needs to match to eat, and the energy spent when a child is eating. If mealtimes
their skill level (versus their chronological age) and is one of are limited to 20 minutes in a school environment, clinicians
the most important steps in the evaluation process. If the child need to consider how many calories the child was able to
needs a modified diet or thickened liquids for a safe swallow, consume versus expend. When children take longer than 30
consulting a physician and the registered dietician is recom- minutes to eat a meal—referred to as inefficient oral feeding—a
mended. The new International Dysphagia Diet Standardiza- modified diet or consultation to a nutritionist should be consid-
tion Initiative provides a universal definition for consistency ered (Goday et al., 2019).
of liquids and food textures on one continuous scale (Cichero For assessing dysphagia in preschool children with CP, the
et al., 2017). This is critical for the child transitioning between Schedule Oral Motor Assessment and the Dysphagia Disorders
environments. Survey have been recognized as having the “strongest clinical
Psychosocial factors is another domain within the PFD’s utility to support clinical decision-making” (Benfer et al., 2012,
definition, and it refers to both the child and the caregiver p. 794). The Rehabilitation Guideline for the Management of Chil-
(Goday et al., 2019). When a child has a PFD, there may be a dren With CP recommends that OTs use the Eating and Drinking
disruption in the bonding process between child and caregiver, Ability Classification System (www.EDACS.org), which was
which is why “many researchers view feeding disorders as a developed for children with CP ages 3 years and older (Human-
relationship disorder” (Didehbani et al., 2011, p. 86). Insecure ity & Inclusion, 2018). A survey of more than 450 pediatric
attachment and difficulty bonding are concerns for children feeding therapists (OTs and SLPs), however, found that most
with CP, because of the child’s limited abilities to communi- clinicians used a non-standardized assessment tool to evaluate
cate their needs to the caregiver (Barthel et al., 2016). feeding skills, followed by VFSSs and the Beckman Oral Motor
Given that the prevalence of feeding difficulties in children Protocol (Barlow & Rabaey, 2020). Feedingflock.com provides
with CP can range as high as 100% depending on the classifi- clinicians with several free assessment tools, such as the Child
cation system (Lagos-Guimarães et al., 2016), clinicians need Oral and Motor Proficiency Scale, Family Management Measure
to include psychosocial concerns in their evaluation process. of Feeding, and the Pediatric Eating Assessment Tool. Feeding
Although not yet widely used across all practice settings, Matters also has a free screening tool available on its website
including a maternal mental health screen as part of the (https://questionnaire.feedingmatters.org/questionnaire).
evaluation process is recommended as best practice (Sepul- Regardless of which assessment tool you choose, it is important
veda et al., 2020). Free maternal mental health screens are that all domains of a PFD are considered and evaluated when
available online, such as the Edinburgh Postnatal Depression appropriate.

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TREATMENT CONCLUSION
A good assessment is the key to successful treatment. It is not Occupational therapy practioners are always focused on the
possible to cover every treatment scenario, but consider a few whole child and providing family-centered care. In treating CP,
key points. An open mouth posture is prevalent in 93% of the primary goal of intervention must be to improve the life of
children with CP (Inal et al., 2017). Training for straw drinking the child and the family (Aggarwal et al., 2015). The complexity
can begin at 6 months (Bahr, 2010); this is critical, as research of the feeding evaluation for the child with CP requires a com-
has shown approximately 80% of children with CP who can use mitment to continued learning and involving the members of an
a straw do not drool (Reid et al., 2012). In addition to drooling, interdisciplinary team for optimal outcomes.
oral motor exercises have been shown effective in improving
tongue lateralization, lip closure, and swallowing evaluation REFERENCES
results (Si an et al., 2013). Aggarwal, S., Chadha, R., & Pathak, R. (2015). Feeding difficulties among
Understanding the phases of swallow, and what is occurring children with cerebral palsy: A review. International Journal of Health Sciences
and Research, 5, 297–308. https://www.ijhsr.org/IJHSR_Vol.5_Issue.3_
in each phase, should guide your clinical reasoning as to why March2015/43.pdf
your client is having swallowing difficulty. Given that children
American Occupational Therapy Association. (2010). Specialized knowledge
with CP often have decreased strength of their oral motor mus- and skills in technology and environmental interventions for occupational
culature, and that swallowing muscles are mostly type II muscle therapy practice. American Journal of Occupational Therapy, 64(Suppl.), S44–
fibers, interventions must be focused on increasing workload to S56. https://doi.org/10.5014/ajot.2010.64S44
increase strength. Therapeutic interventions must be consis- American Occupational Therapy Association. (2015). Occupational therapy’s role
with providing assistive technology devices and services [fact sheet]. https://
tently challenging, such as with increased resistance, to activate www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/
the type II muscle fibers. Repeating the same exercises 10 times RDP/Facts/AT-fact-sheet.pdf
each session for 6 weeks will not activate type II fibers, only American Occupational Therapy Association. (2017a). Occupational therapy
type I. Neuromuscular electrical stimulation (NMES) activates using a sensory integration-based approach with adult populations [fact sheet].
https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/
type II muscle fibers first and is a great therapeutic tool for WhatIsOT/PA/Facts/SI-and-Adults-Fact-Sheet.pdf
increasing the strength of swallowing muscles for children with
American Occupational Therapy Association. (2017b). The practice of occu-
CP (Song et al., 2015). pational therapy in feeding, eating, and swallowing. American Journal of
Free continuing education webinars on treating oral motor Occupational Therapy, 71(Suppl. 2), 7112410015. https://doi.org/10.5014/
skills are available on several websites, including Therapro ajot.2017.716S04
(www.therapro.com/Information-Items/Webinars/), Ages and American Occupational Therapy Association. (2020). Occupational therapy
practice framework: Domain and process (4th ed.). American Journal of
Stages (www.agesandstages.net/courses.php), and OT OER Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/
(https://libguides.aic.edu/OT_OER/webinars). Beckman Oral ajot.2020.74S2001
Motor (www.beckmanoralmotor.com/) and Talk Tools (https:// Arvedson, J. (2013). Feeding children with cerebral palsy and swallowing
talktools.com/) have continuing education courses that focus on difficulties. European Journal of Clinical Nutrition, 67, S9–S12. https://doi.
org/10.1038/ejcn.2013.224
oral motor skills, and are highly recommended.
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottle
and breathing to healthy speech development. Sensory World.
EVALUATION
Barlow, K., & Rabaey, R. (2020). Investigation of assessment tools in the area of
A team approach is always recommended for a feeding eval- pediatric feeding evaluation. [Unpublished manuscript]. Division of Occupa-
uation; however, for a child with CP, this is especially true. tional Therapy, American International College.
Respiratory concerns, along with vision, sensory, cardiopul- Barlow, K., & Sepulveda, A. (2020). The promotion of positive mental health
monary, nutritional, and digestive factors, should be consid- for new mothers during Covid-19. World Federation of Occupational Therapists
Bulletin, 76, 86–89. https://doi.org/10.1080/14473828.2020.1822577
ered in the evaluation process (Stamer, 2016). Depending
on the age of the child and individual interactions, the Barthel, K., Cayo, C., Gellert, K., & Tarduno, B. (2016). The practice of occu-
pational therapy from a neuro-developmental treatment perspective. In
various environments also need to be considered, such as J. Bierman, M. Franjoine, C. Hazzard, J. Howle, & M. Stamer (Eds.), Neu-
day care, school, and home settings. The complexity of the ro-developmental treatment: A guide to NDT clinical practice (pp. 308–324).
feeding evaluation for a child with CP lends itself to the team Thieme.
approach, given the expertise needed for a comprehensive Bashar, M. K., Iqbal, S., Chowdhury, M. A., Das, D., & Iqbal, M. (2015). Devel-
opmental outcome of children with cerebral palsy after feeding and seating
evaluation. intervention. Chattagram Maa-O-Shishu Hospital Medical College Journal,
Examining the four domains of PFDs specific to CP, begin- 14(1), 11–14. https://www.banglajol.info/index.php/CMOSHMCJ/issue/
ning with the medical domain, is a recommended systematic view/1346
approach. For example, constipation and respiratory rate are Bell, K., Benfer, K., Ware, R., Patrao, T., Garvey, J., Arvedson, J., … Weir, K.
(2019). Development and validation of a screening tool for feeding/swallow-
two common concerns. Constipation, due to neuromuscular ing difficulties and undernutrition in children with cerebral palsy. Develop-
factors and decreased mobility, is common, with a prevalence of mental Medicine & Child Neurology, 61, 1175–1181. https://doi.org/10.1111/
26% to 74% in children with CP (Trivi & Hojsak, 2018). Asking dmcn.14220
caregivers how often the child has a bowel movement and the Benfer, K., Weir, K., & Boyd, R. (2012). Clinimetrics of measures of oropharyn-
consistency of the stool can provide important clues in deter- geal dysphagia for preschool children with cerebral palsy and neurodevel-
opmental disabilities: A systematic review. Developmental Medicine & Child
mining hunger, eating habits, and behavior. Neurology, 784–795. https://doi.org/10.1111/j.1469-8749.2012.04302.x

CE-6 ARTICLE CODE CEA0321 | MARCH 2021

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

Brackett, K. (2016). The long road of learning to chew. http://pediatricfeeding- with cerebral palsy. Iranian Journal of Child Neurology, 9(2), 36–41. https://
news.com/the-long-of-road-of-learning-to-chew-part-1/ www.ncbi.nlm.nih.gov/pmc/articles/PMC4515339/pdf/ijcn-9-036.pdf
Cerebral Palsy Alliance. (2015). What is cerebral palsy? https://cerebralpalsy.org. Lagos-Guimarães, H. N. C., Teive, H. A. G., Celli, A., Santos, R. S., Abdulmassih,
au/our-research/about-cerebral-palsy/what-is-cerebral-palsy/ E. M. d. S., Hirta, G. C., & Gallinea, L. F. (2016). Aspiration pneumonia
in children with cerebral palsy after videofluroscopic swallowing study.
Cichero, J., Lam, P., Steele, C., Hanson, B., Chen, J., Dantas, R., … Stanschus,
International Archives of Otorhinolaryngology, 20, 132–137. https://doi.
S. (2017). Development of international terminology and definitions for
org/10.1055/s-0035-1566093
texture-modified foods and thickened fluids used in dysphagia management:
The IDDSI framework. Dysphagia, 32, 293–314. https://doi.org/10.1007/ Lino, T. B., Martinez, L. B. A., Boueri, I. Z., & Lourenço, G. F. (2020). Effects of
s00455-016-9758-y the use of assistive technology devices to promote independence in daily life
activities for a child with cerebral palsy. Revista Brasileira de Eduçacão Espe-
Cieza, A., Causey, K., Kamenov, K., Hanson, S. W., Chatterji, S., & Vos, T.
cial, 26(1), 17–32. https://doi.org/10.1590/s1413-65382620000100003
(2020). Global estimates of the need for rehabilitation based on the Global
Burden of Disease study 2019: A systematic analysis for the Global Burden of Marcus, S., & Breton, S. (2013). Infant and child feeding and swallowing: Occupa-
Disease study 2019. Lancet, 396, 2006–2017. https://doi.org/10.1016/S0140- tional therapy assessment and intervention. AOTA Press.
6736(20)32340-0
Martin-Harris, B., Canon, C. L., Shaw Bonilha, H., Murray, J., Davidson, K.,
Didehbani, N., Kelly, K., Austin, L., & Wiechmann, A. (2011). Role of parental & Lefton-Greif, M. A. (2020). Best practices in modified barium swallow
stress on pediatric feeding disorders. Children’s Health Care, 40, 85–100. studies. American Journal of Speech-Language Pathology, 29(2S), 1078–1093.
https://doi.org/10.1080/02739615.2011.564557 https://doi.org/10.1044/2020_AJSLP-19-00189
DINES. (2019). Vital Stim® Therapy and Beyond. Career Improvement & Advance- Novak, I., Morgan, C., Fahey, M., Finch-Edmondson, M., Galea, C., Hines,
ment Opportunities (CIAO). https://www.ciaoseminars.com/home/vitalstim/ A., … Badawi, N. (2020). State of evidence traffic lights 2019: Systematic
review of interventions for preventing and treating children with cerebral
Edemekong, P. F., Bomgaars, D. L., Sukumaran, S., & Levy, S. B. (2020). Activi-
palsy. Current Neurology and Neuroscience Reports, 20, Article 3. https://doi.
ties of daily living. StatPearls. https://pubmed.ncbi.nlm.nih.gov/29261878/
org/10.1007/s11910-020-1022-z
Erasmus, C., van Hulst, K., Rotteveel, J., Willemsen, M., & Jongerius, P. (2012).
Paul, S., & D’Amico, M. (2013). The role of occupational therapy in the manage-
Clinical practice: Swallowing problems in cerebral palsy. European Journal of
ment of feeding and swallowing disorders. New Zealand Journal of Occupation-
Pediatrics, 171, 409–414. https://doi.org/10.1007/s00431-011-1570-y
al Therapy, 62(2), 27–31.
Feeding Matters. (n.d.). Evaluation & treatment: Feeding skill. https://www.feed-
Poinsett, P. M. (2020). Cerebral palsy facts and statistics. https://www.cerebralpal-
ingmatters.org/what-is-pfd/feeding-skill/
syguidance.com/cerebral-palsy/research/facts-and-statistics/
Fernando, T., & Goldman, R. (2019). Management of gastroesophageal reflux disease
Reid, S., McCutcheon, J., Reddihough, D., & Johnson, H. (2012). Prevalence
in pediatric patients with cerebral palsy. Canadian Family Physician, 65, 796–798.
and predictors of drooling in 7- to 14-year-old children with cerebral palsy: A
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853361/pdf/0650796.pdf
population study. Developmental Medicine & Child Neurology, 54, 1032–1036.
Frakking, T., Chang, A., David, M., Orbell-Smith, J., & Weir, K. (2019). Clinical https://doi.org/10.1111/j.1469-8749.2012.04382.x
feeding examination with cervical auscultation for detecting oropharyngeal
Reidy, T. G., Coker-Bolt, P. C., & Naber, E. (2020). Neuromotor conditions:
aspiration: A systematic review of the evidence. Clinical Otolaryngology, 44,
Cerebral palsy. In J. C. O’Brien & H. M. Kuhaneck (Eds.), Case-Smith’s occupa-
927–934. https://doi.org/10.1111/coa.13402
tional therapy for children and adolescents (8th ed., pp. 764–785). Elsevier.
Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S.,
Ross, E. (2012). Development of feeding progression. In K. VanDahm (Ed.),
… Phalen, J. A. (2019). Pediatric feeding disorder: Consensus definition and
Pediatric feeding disorders: Evaluation and treatment (pp. 35–53). Therapro.
conceptual framework. Journal of Pediatric Gastroenterology and Nutrition, 68,
124–129. https://doi.org/10.1097/MPG.0000000000002188 Sepulveda, A. (2019). A call to action: Addressing maternal mental health in
pediatric occupational therapy practice. Annals of International Occupational
Howe, T.-H., & Wang, T.-N. (2013). Systematic review of interventions used in
Therapy, 2, 195–200. https://doi.org/10.3928/24761222-20190813-02
or relevant to occupational therapy for children with feeding difficulties ages
birth–5 years. American Journal of Occupational Therapy, 67, 405–412. https:// Sepulveda, A, Barlow, K., Demchick, B., & Flanagan, J. (2020). Children’s men-
doi.org/10.5014/ajot.2013.004564 tal health: Promoting mental health through early screening and detection.
OT Practice, 25(4), 10–14.
Hulme, J. B., Shaver, J., Acher, S., Mullette, L., & Eggert, C. (1987). Effects of
adaptive seating devices on the eating and drinking of children with multiple Shepherd, J., & Ivey, C. (2020). Assessment and treatment of activities of daily
handicaps. American Journal of Occupational Therapy, 41, 81–89. https://doi. living, sleep, rest, and sexuality. In J. C. O’Brien & H. Kuhaneck (Eds.),
org/10.5014/ajot.41.2.81 Case-Smith’s occupational therapy for children and adolescents (8th ed., pp.
267–314). Elsevier.
Humanity & Inclusion. (2018). Rehabilitation guideline for the management of
children with cerebral palsy: Occupational therapy guideline. USAID. Si an, S., Uzunhan, T., Aydinli, N., Eraslan, E., Ekici, B., & Çaliskan, M. (2013).
Effects of oral motor therapy in children with cerebral palsy. Annals of
Hurley, D. (2012). Positioning for feeding success. In K. VanDahm (Ed.), Pediat-
Indian Academy of Neurology, 16, 342–346. https://doi.org/10.4103/0972-
ric feeding disorders: Evaluation and treatment (pp. 77–96). Therapro.
2327.116923
Inal, Ö, Serel Arslan, S., Demir, N., Tunca Yilmaz, Ö., & Karaduman, A. A.
Silverman, A., Berlin, K., Linn, C., Pederson, J., Schiedermayer, B., & Barkmei-
(2017). Effect of Functional Chewing Training on tongue thrust and drooling
er-Kraemer, J. (2020). Psyochometric properties of the infant and child feed-
in children with cerebral palsy: A randomised controlled trial. Journal of Oral
ing questionnaire. Journal of Pediatrics, 223, 81–86. https://doi.org/10.1016/j.
Rehabilitation, 44, 843–849. https://doi.org/10.1111/joor.12544
jpeds.2020.04.040
Karagiannis, M., Chivers, L., & Karagiannis, T. (2011). Effects of oral intake of
Simione, M., Dartley, A. N., Cooper-Vince, C., Martin, V., Hartnick, C., Taveras,
water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11, Article 9.
E. M., & Fiechtner, L. (2020). Family-centered outcomes that matter most to
https://doi.org/10.1186/1471-2318-11-9
parents: A pediatric feeding disorders qualitative study. Journal of Pediat-
Korth, K., & Maune, N. C. (2020). Assessment and treatment of feeding, eating, ric Gastroenterology and Nutrition, 71, 270–275. https://doi.org/10.1097/
and swallowing. In J. C. O’Brien & H. Kuhaneck (Eds.), Case-Smith’s occupa- MPG.0000000000002741
tional therapy for children and adolescents (8th ed., pp. 212–238). Elsevier.
Smith, H., Lee, S., O’Neill, P., & Connolly, M. (2000). The combination of
Korth, K., & Rendell, L. (2015). Feeding intervention. In J. Case-Smith, & J. C. bedside swallowing assessment and oxygen saturation monitoring of swal-
O’Brien (Eds.), Occupational therapy for children and adolescents (7th ed., pp. lowing in acute stroke: A safe and humane screening tool. Age and Aging, 29,
389–414). Mosby. 495–499. https://doi.org/10.1093/ageing/29.6.495
Labaf, S., Shamsoddini, A., Hollisaz, M. T., Sobhani, V., & Shakibaee, A. (2015). Song, W. J., Park, J. H., Lee, J. H., & Kim, M. Y. (2015). Effects of neuromuscular
Effects of neurodevelopmental therapy on gross motor function in children electrical stimulation on swallowing functions in children with cerebral

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palsy: A pilot randomized controlled trial. Hong Kong Journal of Occupational

Therapy, 25, 1–6. https://doi.org/10.1016/j.hkjot.2015.05.001
Stamer, M. (2016). Examination. In J. Bierman, M. R. Franjoine, C. Hazzard, J.
Howle, & M. Stamer (Eds.). Neuro-developmental treatment: A guide to NDT
How to Apply for
clinical practice (pp. 74–118). Thieme. he intentional relationship: Occupational
therapy and use of self. F. A. Davis. Continuing Education Credit
Stavsky, M., Mor, O., Mastrolia, S. A., Greenbaum, S., Than, N. G., & Erez, O.
(2017). Cerebral palsy: Trends in epidemiology and recent development A. To get pricing information and to register to take the exam online for
in prenatal mechanisms of disease, treatment, and prevention. Frontiers in the article Evaluation of Feeding, Eating, and Swallowing for Children With
Pediatrics, 5. https://doi.org/10.3389/fped.2017.00021 Cerebral Palsy, go to http://store.aota.org, or call toll-free 800-729-2682.
Toomey, K., & Ross, E. (2013). The S.O.S. sequential oral sensory approach to B. Once registered and payment received, you will receive instant email
feeding. Sensory Processing Disorder Foundation.
confirmation.
Trivi , I., & Hojsak, I. (2018). Evaluation and treatment of malnutrition and
associated gastrointestinal complications in children with cerebral palsy. C. Answer the questions to the final exam found on pages CE-8 & CE-9
Pediatric Gastroenterology, Hepatology & Nutrition, 22, 122–131. https://doi. by March 31, 2024
org/10.5223/pghn.2019.22.2.122
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VitalStim Therapy. (2015). VitalStim Therapy specialty program training manual.
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Final Exam 4. Gastroesophageal reflux occurs:

Article Code CEA0321 A. During the unwanted opening or relaxation of the upper
esophageal sphincter
Evaluation of Feeding, Eating, and Swallow- B. During the unwanted opening or relaxation of the lower
ing for Children With Cerebral Palsy esophageal sphincter
C. When hyolaryngeal excursion is unsuccessful
To receive CE credit, exam must be completed by D. When the pharyngeal shortening is unsuccessful
March 31, 2024
Learning Level: Learning Level: Intermediate to advanced 5. Which of the following is the most recommended assessment to
detect aspiration in children?
Target Audience: Occupational Therapy Practitioners
A. Videofluroscopic swallow study
Content Focus: Domain: Client Factors; OT Process: Occupational Therapy B. Pulse oximeter to monitor oxygen saturation
Evaluation and Intervention
C. Taking temperatures
1. Which of the following phases of swallow is involuntary? D. Cervical auscultation

A. Oral prep phase

6. Which three muscles work together as the muscular sling
B. Anticipatory phase responsible for bolus propulsion?
C. Oral phase
A. Orbicularis, buccinators, and styloglossus
D. Esophageal phase
B. Orbicularis, buccinators, and upper pharyngeal
constrictor
2. In which of the following phases of swallow can aspiration
C. Upper pharyngeal constrictor, styloglossus, and
occur?
geniohyoid
A. Oral prep phase
D. Geniohyoid, mylohyoid, and stylohyoid
B. Oral phase
C. Pharyngeal phase 7. Due to the known difficulties of attachment and bonding for
D. Esophageal phase children and caregivers with feeding concerns, the occupational
therapist can include which of the following in their assessment?
3. In which of the following phases of swallow can reflux occur? A. The Feeding and Nutrition Screening Tool for Cerebral
A. Oral prep phase Palsy
B. Oral phase B. The Schedule Oral Motor Assessment
C. Pharyngeal phase C. The Child Oral and Motor Proficiency Scale
D. Esophageal phase D. Edinburgh Postnatal Depression Scale

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

8. Which of the following exercises has been shown to prevent 11. Which of the following is NOT true regarding the buccinator
drooling? muscle?
A. Tongue lateralization exercises A. It narrows the oral cavity, creating positive pressure
B. Tongue range of motion exercises B. It narrows the oral cavity, creating negative pressure
C. Straw drinking C. It is part of the muscular sling involved in bolus
D. Jaw strengthening exercises propulsion
D. It keeps the food on the teeth while chewing
9. Which of the following is NOT true regarding the muscles
involved in swallowing? 12. The gag reflex affects feeding in what way?
A. Most muscles involved in swallow are Type I muscle A. Its integration facilitates social interactions for speech
fibers. production
B. Most muscles involved in swallow are Type II muscle B. Its integration facilitates children chewing on toys for
fibers. tongue lateralization
C. Neuromuscular electrical stimulation targets Type II C. Its integration facilitates children chewing on toys for lip
muscle fibers first. strength
D. Exercises for swallow must consistently challenge the D. Its integration facilitates bilateral hand coordination for
patient with an increased workload. pacifier use

10. Which of the following is NOT true regarding lip closure? Now that you have selected your answers, you are
only one step away from earning your CE credit.
A. It predicts drooling
B. It creates positive pressure for bolus propulsion
C. It creates negative pressure for bolus propulsion Click here to earn your CE
D. Oral motor exercises have been proven effective in the
treatment of lip closure

ARTICLE CODE CEA0321 | MARCH 2021 CE-9

CE-9