Feeding and Eating Interventions for Children And Youth With Brain Injury

KEEPING CURRENT © Carol DeMatteo, 2003

Support for the research to conduct this critical review comes from a grant from The Economical Insurance Group Economical Insurance Group

This Keeping Current is one of a series of reports that discuss the effectiveness of rehabilitation interventions for children and youth with brain injury.

When reading the Keeping Currents in this series, you will notice that they include research studies that involve children and youth with a variety of conditions. These studies were included because of the limited amount of research on rehabilitation interventions for children and youth with brain injury.

We encourage you to be critical when deciding what information relates to your situation. The most relevant information will come from studies that address the specific condition in question. However, be aware that research findings from studies involving children with different conditions may be relevant when the causes of the conditions are similar ( for example, brain injury and cerebral palsy are both caused by injury to the brain) or when the children's functional difficulties are the same.

Introduction

Feeding and eating are important activities that allow individuals to maintain adequate nutrition. "Feeding" is the term used for offering nutrition to someone who is not able to eat independently, while "eating" refers to the act of taking food independently. Both feeding and eating are social activities that may reflect important aspects of a person's culture and leisure.

Feeding and eating are also activities that most people take for granted. However, they are very complex processes that involve the use and co-ordination of many muscles. When children have an injury or a disorder that affects their nervous system and muscles, their ability to eat (or to be fed) can be affected.

This paper outlines general concepts of feeding and eating, and discusses issues that can occur when a child has an acquired brain injury. The final section focuses on what is known about feeding assessments and interventions for children with acquired brain injury (ABI).

Feeding - General Concepts

Oral Feeding

Oral feeding is the process of taking food by mouth - this is the ultimate goal of feeding interventions because it is what we typically do in our daily lives. The process of oral feeding and swallowing is described by stages.

First, the food is chewed and is moved to the back of the mouth - the oral phase. When the food reaches the back of the mouth into the pharynx (throat), a swallow is triggered. This marks the beginning of the pharyngeal phase of the swallow. Muscles in the pharyngeal area work to close off the airway and direct the food toward the esophagus, the tube that leads to the stomach. A swallow is "safe" when all of the food goes into the esophagus and no food enters the airway or lungs. Once the food enters the esophagus, it is moved to the stomach by muscle movements called peristalsis - the esophageal phase.

Tube Feeding

Food can be taken into the body through a nasogastric tube that goes from the nose to the stomach or to the small intestine. This is usually the first method used when a child has had a significant brain injury and is not yet ready to eat by mouth. More serious or long term feeding problems may require a gastrostomy tube that is put directly into the stomach by surgery. There is also a type of feeding that occurs through an intravenous line, called parenteral feeding. This is usually only used for short periods of time, if ever, with children after brain injury.

How does feeding typically develop?

Young infants generally receive all of their nutrition from liquid. As they develop, they are introduced to smooth pureed solid food. Gradually, they are able to handle thicker purees and foods that are easy to chew. By two years of age, children are typically able to eat foods similar in texture and quality to adult diets, with some modifications for safety. This progression of food types is related to the child's developing abilities to co-ordinate the muscles that are used for chewing, swallowing and breathing.

The sensory aspect of eating, which includes taste, temperature and texture, is also an important part of the whole picture. Some children have strong aversions to certain tastes and textures and will try to avoid these foods.

Children with Acquired Brain Injury and Feeding

What is an Acquired Brain Injury?

The term acquired brain injury (ABI) includes all causes of injury to the brain. Despite improvements in the delivery of trauma care, traumatic brain injury after head injury persists as the leading cause of death and long-term disability in children (Centre for Disease Control, 2000; Discala et al., 1997). The impact of ABI on a child will depend on the child's injury. For some children, the injury will affect many different systems in their body and will cause long-term problems.

What is the connection between ABI and feeding problems?

Most children with severe ABI will have feeding difficulties in the early stages of recovery. ABI often affects how a child is able to use their muscles. If the injury has affected the muscles that are used for eating, they will have difficulty managing many of the stages of eating. Eating will also be affected by the ability level of consciousness or alertness. Safety is a major concern because the child may be at risk of choking or aspirating (having the food or liquid go "down the wrong way" into the airway and lungs) during eating, which may cause aspiration pneumonia.

Adequate nutritional support is a vital part of recovery and must be delivered by nasogastric tube if the child is unable to take enough calories by mouth. Some children will have more severe or prolonged feeding problems and may require a gastrostomy tube.

Ylvisaker & Weinstein (1989) reviewed the literature on the recovery of oral feeding after head injury. They reported that the most commonly seen problems include reduced muscle co-ordination and difficulty with food manipulation in the mouth, delayed triggering of the swallowing reflex, and poor movement of food through the mouth and pharynx. The majority of children with neurological impairment who aspirate have an intact swallowing reflex (Lazarus & Logenmann, 1987). It is thought that their feeding problems are most likely due to the poor co-ordination of the tongue, lips, cheeks, and larynx (Morris, 1989; Leopold, 1983).

Because of the issues listed in the previous paragraph, many children will experience mild aspiration on the path to oral feeding. In a case control study comparing children who developed pneumonia with controls who did not, Taniguchi and Moyer (1994) found that children with ABI were 5 times less likely to develop pneumonia than children with other diagnosis. They also found that children who aspirated puréed consistencies had a nine-fold greater risk for pneumonia than comparable children who did not aspirate this consistency. Children who aspirated thickened liquids were at intermediate risk, having a 2 to 6 times greater chance of having pneumonia. Children who aspirated only thin fluids did not have a statistically significant increase in pneumonia risk.

Although aspiration must be taken very seriously, individual tolerance for amount and type of aspiration remains variable (Groher, 1994). Buchholz (1999) cautions that we may do more harm than good by advising parents not to allow their children to eat after documentation of aspiration especially in individuals who have been eating without lung complications. Further research is required in this area to develop clear guidelines. Until this is done, it is likely that there will be discrepancy among health professionals regarding the introduction of oral feeding.

Addressing Feeding Problems in Children and Youth with ABI

When a child is unable to eat by mouth, the road to independent eating usually starts with tube feedings. If the child is still unable to eat by mouth a few days after injury, the child will start a therapeutic oral feeding program while receiving his or her nutrition by tube. A primary goal of feeding interventions and programs is to ensure that the child can eat safely without choking or getting food in their airway (aspirating). Once safety is established, therapy focuses on increasing the amount and range of foods a child can eat, with the goal of discontinuing tube feeding. Assessment of the child's feeding is ongoing throughout the feeding program to ensure that the safest and most effective feeding arrangements are in place.

Feeding Assessments

When a child is having difficulty eating, a referral will be made for a feeding assessment. Typically, occupational therapists or speech language pathologists who are trained in the area of feeding and swallowing will conduct the assessment.

The first step of the assessment involves a clinical evaluation. The therapist will meet with the child and family. A feeding history will be collected and when appropriate, the child will be observed eating. 

The therapist will be observing many things during the assessment including:

• the child (including his/her oral motor function, muscle tone, posture, sensory response, feeding behaviour, and self- feeding ability)
• the physical environment (for example, the child's chair, table, feeding utensils)
• the social environment (for example, parent-child interactions)
• the demands of the feeding task (for example, volume of food, how fast it is fed, type of food) (Ylvisaker, 1998)

From this clinical assessment, the team can determine if the child is safe to eat, if strategies are needed to improve the child's ability to eat safely, or if further assessment is required (Cherney & Halper, 1989; Newman, 2000; Rowe, 1999; Schauster, 1996; Trier & Thomas, 1998; Ylvisaker & Weinstein, 1989).

The main limitation of a clinical evaluation is that it is not possible to see what happens in the pharynx (throat) and esophagus (tube leading to the stomach) during and after swallowing. Listening to the swallow with a stethoscope is thought to improve this, however, its effectiveness has not been proven in research (Zenner et al., 1995). If the therapist is concerned that a child's swallow may not be safe, a referral will be made for a videofluoroscopic swallowing study (VFSS).

VFSSs are videotaped x-rays that show how food passes from the mouth through the pharynx. A VFSS is usually recommended to evaluate the unseen stages of swallowing and it is accepted as the best way to check to see if the child is aspirating food or fluid into the airway (Arvedson et al., 1994; Bucholz, 1999; Lazarus & Logeman, 1987; Loughlin, 1989; Morris, 1982; Parrish, 1997; Ylvisaker & Weinstein, 1989). However, VFSSs do expose children to radiation, and they are expensive and resource intensive. Further, they provide only a brief sample of swallowing performance, and can be an unpleasant experience and frightening for some children. VFSSs are not needed for all children, but are very important when it is suspected that a child is aspirating food or liquid.

Feeding Intervention

Few studies have been conducted that only include children and youth with ABI. As such, the following review includes studies of children with a variety of diagnoses and some studies that included children and adults. When deciding whether or not the information relates to your situation, it is important to consider whether the group of children in the study are similar to your situation.

Nutrition

Severe brain injury produces a situation in which the individual has increased nutritional and metabolic requirements (Clifton et al.,, 1986; Pepe & Barba, 1999; Taylor et al., 1999). This state has been associated with an increased risk of infection and impaired immune responses. The studies in this area have focussed on adult populations with severe and moderate ABI, but the formulas for nutritional management that have arisen from these investigations are useful in the management of children with ABI.

In a clinical trial, Taylor et al. (1999) built on the work of Ott et al. (1987) and Young et al. (1987) to demonstrate a significant decrease in infection and complication rates in individuals after ABI, who were fed enhanced nutrition (given by nasogastric tube). Enhanced nutrition was defined as a feed rate and calorie intake that would meet the individual's full estimated requirements from the first day following injury.

For children transitioning from tube to oral feeding Schauster & Dwyer (1996) have recommended discontinuing tube feeding when the child is taking at least 75% of their needed calories by mouth. If the child has a gastrostomy tube (G-tube) then the G-tube should remain in place until more than 6 weeks of consistent oral eating is achieved.

Behavioural Interventions

Although not specific to children with ABI, behavioural feeding programs have been described for children. However, behavioural feeding approaches have not been well-researched and the articles on these techniques are generally descriptive with a focus on clinical issues.

Wolff & Lierman (1994) present an organized approach to using behavioural management techniques for feeding problems. They suggest that variables relating to time, space, child, feeder and food are all important to consider. They also suggest treatment methods to increase certain behaviours, as well as methods to decrease behaviours.

Luiselli (1994) and Cooper et al. (1995) both present single case studies involving children with a variety of diagnoses (but none with ABI). They report that behaviour modification techniques using "component analysis" and "treatment packages" resulted in improved oral consumption and food acceptance.

Food Texture Interventions

Different food textures can cause different responses in a child and changing the food's texture can make a difference in a child's ability to manage food in his/her mouth and to swallow. (Couriel et al.,1993; Linden, 1989)

When changing food texture, therapists typically begin with the texture that is easy for the child to manage. Smooth pureed foods (such as pudding) are generally the easiest consistency to eat. The slightly thicker, heavier consistency of the puree moves more slowly than an liquid, allowing a child more time to coordinate the swallow. The smooth texture means that the child does not have to chew the puree before swallowing. However, when the puree is very thick (such as mashed potatoes) it can be more difficult for the child to eat because it tends to stick in the mouth and throat, requiring the muscles to do more work.

Liquids, which move quickly through the mouth and the throat, can pose a major problem for infants and children who have difficulty co-ordinating breathing and swallowing. Solid foods, such as crackers or meat, can present difficulties because they must be chewed by the child before being swallowed. Chewing involves co-ordinated jaw, lip, cheek, and tongue movements. Mixed consistency foods (such as soup with broth and pieces of vegetables) can also be challenging because the child must be able to handle the liquid and the solid.

Traditionally, liquids, especially water, are encouraged in the initial stages of feeding children and adults with neurological impairment because there may be less damage than non-water items if they are aspirated into the lungs. However, as discussed above, liquids and very thin puréed foods may actually be the most difficult to eat because they are thin and move very quickly (Ylvisaker, 1998). In addition, liquids provide a feeling of fullness, and should be avoided early in the meal, if greater consumption is desired.

Ylvesaker and Weinstein (1989) stated: "Since children with head injury often tolerate puréed foods better than thin liquids or solids it is usually appropriate to begin evaluation with this consistency" (p. 56). Cherney and Halper (1989) also supported the importance of texture and in particular puréed texture in the recovery of oral feeding after acquired brain injury in adults. Trier and Thomas (1998) stress that oral intake may be improved by a change in posture, mashing or puréeing lumpy food, thickening of liquids and other feeding techniques and equipment.

In a research study of three children with severe brain injury, the effect of food texture on the amount of intake by mouth and oral motor function was examined (DeMatteo et al., 2002). These three single child studies demonstrated that early feeding programs can increase intake by mouth. Different people feeding the child, different food textures and day to day changes within the child can affect how much the child can eat during the early recovery period after ABI. Consistent feeders are important to the success of early feeding programs.

Another research study by Croft (1992), which compared 67 children with cerebral palsy (CP) and 67 children without CP, showed that food texture could significantly affect dietary intake of children with poor oral skills and ultimately their nutritional state. Her conclusion was that, mashed food rather than soft food (that needs to be chewed) should be the main type of meal for those who cannot chew.

In a study that looked at the effect of oral sensorimotor intervention with children with cerebral palsy, texture was found to be a factor contributing to the risk of aspiration. The soft texture presented the greatest difficulty for the children with CP (Gisel et al.,1996).

Griggs (1989) explored feeding time, the ability to deal with different food consistencies, aspiration and the effect of different positions on ten patients with cerebral palsy age nine months to 24 years. Their findings indicate that individuals showed delay of swallow depending on the consistency of food. Paste was aspirated in more cases than liquid. There were decreased episodes of coughing and choking based on texture changes in the diet. However, changes in weight and numbers of chest infections were not found suggesting that there was no long-term or carryover effect.

In a case series, Rogers et al. (1993) demonstrated that periods of hypoxemia (decreased oxygen) during meals were dependent on food texture in three of five children with severe cerebral palsy. The authors felt that the hypoxemia was probably due to aspiration. Recommendations depended on the degree of hypoxemia and ranged from changing diet textures to stopping oral feeding for some children.

The fact that many authors continue to make different recommendations regarding texture, reinforces the need to evaluate the use of food texture as an intervention to improve oral intake and progress quickly beyond tube feedings. At the same time, the children's high caloric needs must be met and aspiration prevented.

Summary

Nutrition, safety, return to regular eating routines, independence and caregiver involvement are the main factors in all feeding intervention programs for children with ABI.

Each child with a brain injury who has difficulty eating must be evaluated carefully by an experienced clinician. Further tests may then be administered as required. Based on the findings of these assessments, a carefully planned and sequenced feeding program designed to be compatible with the child's individual needs and abilities should be developed (Arvedson & Lefton-Greif, 1996; Christensen, 1989; Leifton-Greif & Loughlin, 1996). The planning and implementation of these programs should involve the child's family and primary caregivers.

Depending on the type of oral motor problem and the safety of swallowing, tube feeding may be required either to supplement, or to replace oral feeding. Morris (1989) and Christensen (1989) support the point of view that if tube feeding is used, it is important to continue a safe oral motor stimulation or therapeutic feeding program.

As outlined in this research summary, there is a lack of evidence supporting the interventions currently used to help children and youth who have brain injury and feeding problems. The effectiveness of each of these interventions still needs to be studied more rigorously in children with ABI.

Prepared by:

Carol DeMatteo, MSc., OT Reg. (Ont.), Associate Clinical Professor, School of Rehabilitation Science and Associate Member, CanChild, McMaster University.

For more information, please contact: Carol DeMatteo, MSc., OT Reg. (Ont.) at canchild@mcmaster.ca