Cerebral palsy (CP) is a group of disorders affecting a person’s ability to move, caused by damage to the developing brain either during pregnancy or shortly after birth. Children with cerebral palsy often face unique challenges when it comes to nutrition. Because CP can affect muscles throughout the body, including those involved in swallowing and digestion, children with CP often suffer from malnutrition due to limited oral-motor function. This article provides a detailed overview of dietary recommendations and strategies to ensure optimal nutrition for children with cerebral palsy, addressing various factors and practical solutions.
Understanding the Nutritional Needs of Children with Cerebral Palsy
Every child needs a well-balanced diet to support their growth and development. Children with cerebral palsy have different dietary needs than other kids. This applies to required nutrients as well as recommended foods. Because every case of cerebral palsy is unique, each individual will have different nutritional needs. Several factors can affect an individual with cerebral palsy’s dietary needs:
Severity of Motor Impairments
Cerebral palsy describes a spectrum of motor impairments at varying severities. Generally, individuals with milder motor impairments are more physically active and require more energy intake.
Oral Motor Impairments
If cerebral palsy affects the muscles around the mouth, individuals may struggle to chew and swallow their food. Symptoms of cerebral palsy in children include low muscle tone, weakness in the muscles of the face, tongue, jaw, and throat. This can make it challenging for them to chew food, and it may be difficult for them to swallow safely.
Premature Birth
Premature birth is a common cause of cerebral palsy. Infants born prematurely are often smaller, which should be taken into consideration when accessing their dietary needs. About 85% of children born prematurely catch up to their developing peers during the first 2 years of life.
Read also: Facial Palsy: A Comprehensive Guide
Co-occurring Complications
Some children with cerebral palsy have gastrointestinal reflux disease, which can cause stomach acid to irritate the esophagus and cause heartburn. Individuals with severe oral motor impairments may need to use a feeding tube. While many parents may be opposed to a feeding tube, it’s essential to prioritize your child’s nutrition as they grow. Your child may not have to solely rely on the feeding tube.
To better understand your child’s specific nutrition needs, speak with their pediatrician or a dietician. A nutrition therapist or counselor also provides education and awareness to parents and caregivers, which helps them implement the child’s nutritional needs at home and school. Nutrition counselors and dietary therapists can be found in various professional settings. Children with cerebral palsy often have a team of medical providers to ensure that all of their needs are met.
Essential Nutrients for Children with Cerebral Palsy
Children with CP need to get a variety of vitamins and minerals, just like everyone else. But sometimes, they might need more or fewer calories depending on their activity level and muscle tone (how "tense" their muscles are at rest). For example, a child with high muscle tone and a high activity level will use more energy and need to eat more than a child with low muscle tone and a low activity level. Several nutrients are particularly important for children with cerebral palsy:
Protein
Protein intake plays a key role in promoting muscle development and tissue growth. Children with CP may have muscle weakness or spasticity, which can lead to increased protein needs.
Calcium
Low bone density is a common problem for people with cerebral palsy, so foods and beverages with calcium are a must. Children with severe cerebral palsy often develop osteopenia, a medical condition marked by fragile bones due to decreased calcium. Around 99% of calcium is contained in the skeletal system. The rest has the critical duty of controlling blood pressure, soft tissue function, and muscle movement. Calcium helps secrete hormones and regulate blood flow.
Read also: The Hoxsey Diet
Vitamin D
Vitamin D is a nutrient that can help the body absorb calcium. It’s also easy to get deficient when you spend a lot of your time indoors, so kids with CP are more susceptible to it than their peers. Vitamin D can be taken in pill form or obtained from fish, milk and orange juice.
Phosphorus
Phosphorus is good for bones and teeth, two things that can take a hit when your child has cerebral palsy. Phosphorus is a key mineral for strong teeth and bones. It can be obtained through the consumption of dairy products or whole grains. It's found in milk and milk products, meat, fish, eggs, poultry, nuts, seeds, and whole grains.
Iron
Children with CP may be at increased risk for anemia due to limited mobility or poor nutrient absorption. Iron is important for red blood cell production.
Fiber
Constipation is a common problem for children with CP. Adequate fiber intake can help promote regular bowel movements. The dietary fibers found in whole grains are called prebiotics.
Magnesium
Magnesium is vital in producing energy, assisting in cell communication, synthesizing molecules, and helping children build strong bones.
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Vitamin C
Many children with cerebral palsy suffer from mood swings, depression, and anxiety. They may lack enough vitamin C to synthesize the norepinephrine neurotransmitter in the brain.
Copper
Copper is an important trace mineral in the brain, heart, kidneys, skeletal muscles, and liver. It helps increase iron absorption, maintain collagen, and ward off infections.
Choline
Choline is a nutrient necessary to produce acetylcholine, a neurotransmitter that affects mood, memory, muscle control, and other essential nervous system functions.
Dietary Strategies and Food Recommendations
There’s no “one size fits all” diet for cerebral palsy. A child’s needs vary depending on age, height, weight, growth, and physical activity level. The care team will make a dietary plan based on this information. The plan helps you make sure that your child grows well and maintains a healthy weight. Your child's growth and diet will be checked at follow-up doctors' visits. If your child isn't growing as expected or getting the right nutrition, the plan will be updated. Kids' nutritional needs change as they get older, so it's important to follow up with your care team at least annually as your child grows. Here are some general dietary strategies and food recommendations:
High-Calorie and Nutrient-Dense Foods
Many individuals with cerebral palsy may be undernourished because of difficulties controlling the muscles around the mouth. High-calorie and nutrient-dense foods like avocados help ensure that individuals with CP are eating enough calories without needing to increase the volume of food they eat. They’re also extremely versatile and generally kid-approved.
Leafy Greens
Leafy greens also contain folate, a B vitamin that’s necessary for the synthesis of serotonin, epinephrine, norepinephrine, and dopamine.
Whole Grains
Many individuals with cerebral palsy experience digestion problems due to reduced metabolic rates. Many individuals with cerebral palsy sit in a wheelchair for most of their day.
Ginger
Ginger is a root that has been used for culinary and medicinal purposes for thousands of years. Ginger is full of antioxidants, which may protect the brain by combating oxidative stress.
Texture Modifications
Preparation is key when it comes to feeding a child with cerebral palsy. Dietary practitioners can adjust textures and consistency of food by pureeing, chopping and grinding foods for a more palatable experience. Foods can be softened by adding broth, gravy, milk, or juices to accommodate constipation issues.
A child's diet should include foods with a variety of textures to encourage mastering the skills of swallowing and chewing. With the direction of the feeding team, be sure to help the child with special needs advance to more texture in her food. When offering a new texture to an infant or child, offer a few spoons of the familiar texture first, then the new texture. For example, when going from pureed to mashed/lumpy, offer blended carrots first - then fork-mashed carrots. Learn to accept the mashed/lumpy texture without feeling rushed.
Some children may have trouble swallowing thin liquids, so you will need to thicken the liquid. The child may have trouble swallowing dry or lumpy foods. Gagging and choking can either be a sign of aversion to something new and different, or a sign that the child is having trouble swallowing. Offering the wrong texture can cause gagging and choking. Offering new textures may cause gagging, even if the feeding team has recommended the new texture. Gagging may be a behavioral response. Positioning of the child can affect swallowing. If gagging and choking are chronic problems, it must be followed by a health care specialist.
Foods to Avoid
Even with good oral motor control, choking can happen to any child. Here are some foods to avoid and food preparation techniques to help prevent choking:
- Cook foods until soft enough to easily pierce with a fork.
- Cut foods into small pieces or thin slices that can easily be chewed.
- Cut round foods like cooked carrots into short, thin strips rather than round pieces.
- Grind or mash and moisten food for young babies.
- Remove all bones from poultry, fish, and meat.
- Remove skins, pits, and seeds from fruit.
- Avoid nuts or seeds (such as sunflower or pumpkin), unless ground finely or chopped.
- Avoid plain peanut butter - always put on bread or crackers.
- Avoid popcorn, grapes, and hot dogs.
Meal Replacement Beverages and Smoothies
You might also consider meal replacement beverages and other easy-to-swallow foods like smoothies.
Addressing Feeding Difficulties and Dysphagia
Many children with cerebral palsy experience feeding difficulties and dysphagia (difficulty swallowing). Dysphagia is difficulty swallowing and is evaluated by a professional speech pathologist and multidisciplinary team. This evaluation is performed through clinical observation, in addition, objective (or laboratory) evaluation methods can be used, such as videofluoroscopy and fiberoptic endoscopy swallowing (FEES). Here are some strategies to address these challenges:
Proper Positioning
It is very important to take care of the posture at the moment of feeding, since a correct posture improves the effectiveness for chewing and swallowing safely. Legs should be bent in a sitting position (about 90 degrees). Feet should rest flat on a firm surface.
Oral Motor Control Techniques
During the feeding process, we must consider the way of approaching the spoonful of food, which must always enter from the bottom up and front, placing the well with the food in front of the child. This favors anticipation of the food process. A common precaution is to fill the spoon with food only halfway. One of the most common problems is that the child can not close their mouth (lip closure), which is related to oral motor control. The first is the frontal oral motor control. In both cases, the hand must be firm, without too much force or pressure. It is only a support.
Managing Sialorrhea
Sialorrhea is the unintentional loss of saliva from the mouth.
Addressing Delayed Laryngeal Elevation Reflex
The reflex laryngeal elevation (10-15 mm) supports the closure of the airway and the passage of food into the esophagus. A normal delay is between 0.8 and 1 second.
Preventing Penetration and Aspiration of Food
The penetration of food occurs when it is above the level of the vocal cords, without getting to enter the lungs. In the aspiration the food enters the lungs (which can provoke pneumonias or other respiratory symptoms), being able to catch reflex of cough or to be a silent aspiration (without reflex of cough). The cough allows expulsion of foreign bodies entering the airway, this is a measure of natural protection (physiological) that the human body has, in some children or young people with cerebral palsy this reflex is absent or greatly diminished.
Correcting Chewing Patterns
Insufficient control of the mandible favors the appearance of incorrect chewing movements (patterns). Proper mastication involves vertical, lateral and rotational movements, with adequate closure of the lips or mouth, which prevents food from escaping from the mouth.
Monitoring Voice Changes
When food penetration or aspiration occurs, the mucous membrane covering the vocal cords is modified; this change produces a change in the voice and is what we call speech therapists a "wet voice".
Managing Primitive and Pathological Reflexes
Primitive reflexes are all those that are present from birth to the age of abolition and are part of the normal development of the human being. These reflexes are: suction reflex, search reflex, bite reflex and arcade reflex. The pathological reflexes are all those that are present in front of an alteration of the nervous system and are not part of the normal psychomotor development of the child.
Selecting Appropriate Utensils
For the correct delivery of the food you must use a suitable food utensil. These can be spoons (metal or plastic) vases, plates, forks, etc. All these utensils can be those of daily use or with adaptations. From time to time they should be checked for condition and replacement due to wear.
The spoon should never be larger than the tongue of the child, girl or young person. If there is a strong bite, use a plastic spoon that is strong.
Feeding Methods
- Breastfeed: The use of a bottle should be for those children who have a safe swallowing of liquids.
- Spoon: This is the main food utensil; it an be metal or plastic.
Portion Sizes
Size of the serving portions: It is recommended to give small or reduced portions, but with high calories and nutrient intake. E.g.
Consistency and Texture
It is important that the food forms smooth and homogeneous dough without lumps and thorns, easy to swallow or chew, for example creams, fruit or vegetable puree, yogurt. You should avoid textures where the liquid is mixed with the solid: E.g. 1. Solid food: crushed, pure, soft food 2. Liquid food Liquids are problematic for children or young people with dysphagia; it is necessary to increase their consistency to facilitate the intake. For this we can use thickeners such as fine flour (cornstarch), instant cereals or use other formulas indicated by medical staff. Some examples of consistency are: nectar-like, honey-like, pudding thick.
When to Consider Tube Feeding
If your little one is refusing even liquid-based nutrition, it might be time to think about tube feeding. Feeding tubes provide nutrition without the need to chew and swallow. When oral feeding becomes a dangerous route, there are alternative options:
- Nasogastric tube: It is a food route, which runs from the nose to the stomach. Its use is recommended when it is anticipated that the need to contribute by this route will not be more than 4 to 6 weeks in duration and there is no gastroesophageal reflux.
- Gastrostomy: It is a food route that goes directly to the stomach, is implanted when the oral route is not used in a prolonged way (beyond 4-6 weeks). The advantages of a gastrostomy are that with this food route it is easier to handle at home and there are fewer risks of injury (nose, throat) and the main thing allows the incorporation of more food in comparison to the nasogastric tube.
- Mixed: Both feeding routes are used (oral + nasogastric or Gastrostomy).
Consider keeping a food diary to track your child’s daily food and drink intake. It can help a nutrition therapist understand your child’s eating patterns before an assessment. Deciding to use a feeding tube can be difficult for parents who want their child to eat normally. Sometimes, a feeding tube is the best option to ensure adequate nutrition while limiting the safety issues associated with chewing and swallowing.
The Role of Nutrition Therapy and Counseling
Nutritional interventions can improve symptoms and help manage associated conditions. A nutrition therapist or counselor also provides education and awareness to parents and caregivers, which helps them implement the child’s nutritional needs at home and school. With the majority of individuals with Cerebral Palsy reporting feeding or digestive difficulties, a dietary counseling program can be highly beneficial. Skilled practitioners work with primary care physicians to adjust diet, intake, substance, and supplements in ways that contribute significantly to an individual’s overall health.
Nutritionists and dietitians assess, plan, and implement dietary plans to meet the unique needs of the individual, taking his or her health conditions, cultural requirements, and environmental needs into account. The nutritionist or dietitian maintains professional and interdisciplinary relationships with care plan team members in an effort to understand, monitor and evaluate health care needs. The primary focus is on input that impacts the dietary and exercise requirements of the nutrition and dietary plan. The nutritionist or dietitian will analyze data from medical history, clinical discoveries, and lab results for a detailed assessment of the person’s needs, habits, behaviors, support system, and environmental influences.
Components of a Dietary Plan
Diagnostic history - data from the following: acid-base profile, electrolyte profile, fatty acid profile, gastrointestinal profile, glucose/endocrine profile, inflammatory details, lipid profile, metabolic rate, mineral levels, nutritional anemia, protein profile, urine profile, and vitamin levels. Also includes overall appearance, body language and test results for: cardiovascular-pulmonary system, muscles and bones, digestive functioning, nerves and cognition, skin health, and vital signs (blood pressure, heart rate, respiratory rate and temperature).
Gaining insight from the findings for the consults and assessments, the nutritionist/dietitian will then consider the challenges, solutions, costs and timing elements for an effective and efficient dietary plan. The plan must contain access to supportive food venues with healthy food choices at reasonable portion sizes. The plan must be convenient, available and affordable.
The nutritionist and dietitian will be responsible for providing information, options, assisting with choices, educating, training, and implementing the plan. These practitioners work with clients to commit to a plan, its time frame, and the demands. In order for a change in behavior to take place, shifts in habits, attitudes and intentions must also occur. Change requires time, commitment, and support.
Teaching others to change established habits, and learn healthier ways of consuming food and fluids is not always easy; many barriers to change exist. Understanding the client’s habits, preferences, environment, cultural beliefs, and abilities are essential in the planning process. Many with Cerebral Palsy are prescribed liquid or semi-solid foods. Some are tube fed. Dietary practitioners realize behavioral change is not always easy to embrace. Nutrition and dietary plans may require purchasing different foods from different venues and preparing food in different ways. In addition, the plan may require food to be consumed in a manner that may require training, adaptive equipment, or the placement and use of feeding tubes.
Dietitians will follow up with clients to discuss progress, identify stressors and reconfigure options. A successful plan requires focus on the goals, as well as an open communication process. It is always helpful to have supportive family and friends. Practitioners who administer dietetic counseling and meal-planning services are likely educated in food and nutrition sciences, culinary arts, and food service systems management.
Special Diets and Supplements
Ketogenic Diet
A few diet plans have proven to be beneficial to children with cerebral palsy. The ketogenic diet has been proven beneficial for children with cerebral palsy who experience frequent seizures. It consists of low-carb and high-fat foods. The high-fat foods cause ketosis, a condition where the ketones in the body increase.
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