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Feeding Difficulties

Undernutrition is common in children with cerebral palsy (CP) and assessment of a child’s food and fluid intake is fundamental to developing a nutritional care plan.

There are different ways to assess a child’s intake, including a 3-day review of the child’s diet or a 24-hour recall.

Determining if your patient has feeding issues

Addressing feeding difficulties may prevent undernutrition, growth failure, micronutrient deficiencies, osteopenia, and nutritional comorbidities.1

Asking caregivers the following questions may help you better evaluate the situation:2

  • Does feeding time take longer than 30 minutes?
  • How would you describe mealtimes? Are mealtimes stressful for you and your child?
  • Have you observed a lack of weight gain for the past 2–3 months, especially in the first 2 years of life?
  • Does your child have a history of respiratory illnesses?
  • Have you observed increased nasal congestion at meal times?
  • Have you noticed a change in voice quality during meal times?

If possible, identify the specific feeding issues of your patient with CP by observing how your patient eats.

If you suspect the presence of swallowing difficulties, it would be preferable to have an assessment done by a local specialist multidisciplinary team with training in assessing and treating dysphagia. Your patient may be referred for further evaluation with a video fluoroscopic swallow study, also known as a modified barium swallow, or a fiberoptic endoscopic evaluation of swallowing (FEES) may be recommended.2,3

assessment flowchart



  1. Romano C et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children with Neurological Impairment. J Pediatr Gastroenterol Nutr. 2017;65(2):242-264.
  2. Scarpato E et al. Nutritional assessment and intervention in children with cerebral palsy: a practical approach. Int J Food Sci Nutr. 2017;68(6):763-770.
  3. National Institute for Health and Care Excellence. Cerebral palsy in under 25s: assessment and management. Full Guideline. NG62. 2017. Accessed November 7, 2018 at:

Swallowing difficulties, or dysphagia, are a prevalent concern among children with neurological conditions, and have been reported to affect up to 90% of children with CP.1 While there may be variability in the features and severity of swallowing problems in children with CP, dysphagia may have clinical and social implications including swallowing safety or efficacy, the ability to consume adequate nutrition and hydration, and quality of life.1,2,3

Children with dysphagia may have difficulty managing certain foods and/or fluids. While the degree and severity of dysphagia and its nutrition implications vary, even children with mild CP may have dysphagia. Children with generalized severe motor impairment (for example, spastic quadriplegia) are likely to experience more profound swallowing deficits.3

Signs and symptoms of dysphagia may include:1-3

Physical Behavioural
Coughing and/or choking during eating Changes in eating or drinking habits, either gradual or sudden
Changes in facial colour while eating or drinking Does not want to eat
Fatigue during meals Avoiding certain foods and drinks
Difficulty retaining food in the mouth Taking a long time to eat or drink
Excessive food remaining in the mouth Wanting to eat alone
Coughing that persists after eating
Failure to gain weight/inadequate growth
Recurring chest infections
Altered breathing patterns
Sweating during meals

A thorough history and evaluation can help determine if a child with CP has dysphagia. Evaluation tools may include:2-4

  • Detailed feeding history, including reported clinical signs/symptoms during and after eating/drinking, fear or avoidance of eating and prolonged stressful mealtimes
  • Physical examination and medical history, including a neurological examination, history of recurrent respiratory infections and weight/growth patterns
  • Mealtime observation
  • Modified barium swallow (videofluoroscopy)
  • Fiberoptic endoscopic evaluation of swallowing (FEES)

Dysphagia can not only lead to malnutrition and dehydration but can also impact quality of life and cause a number of respiratory problems, such as pneumonia, due to recurrent aspiration.2-4 In some children, aspiration may be silent and not stimulate any cough response, making detection a challenge requiring attention to clinical signs and medical history.3

Given the multifaceted nature of dysphagia, management requires collaboration of a multidisciplinary team.

Strategies to help manage dysphagia may involve adapting the texture and consistency of your patient’s foods and liquids and attention to the child’s posture during and after meals.




  1. Marchand V Canadian Pediatric Society, Nutrition and Gastroenterology Committee. Nutrition in neurologically impaired children. Paediatr Child Health. 2009;14(6):395-401.
  2. van den Engel-Hoek L, de Groot IJ, de Swart BJ and Erasmus CE. Feeding and Swallowing Disorders in Pediatric Neuromuscular Diseases: An Overview. J Neuromuscul Dis. 2015;2(4):357-369.
  3. Arvedson JC. Feeding children with cerebral palsy and swallowing difficulties. Eur J Clin Nut. 2013;67:S9-12.
  4. National Institute for Health and Care Excellence. Cerebral palsy in under 25s: assessment and management. Full Guideline. NG62. 2017. Accessed November 7, 2018 at:

Gastroesophageal reflux disease, also known as GERD, is another common feeding difficulty.1,2 It happens when stomach content rises back up in the esophagus. GERD can cause pain, vomiting and harm to the esophagus because the liquid that comes back up contains acid from the stomach, as well as enzymes and bile. GERD can be controlled through nutritional strategies and specific medications that can be prescribed.

Lifestyle recommendations can also help in alleviating the condition, such as correct positioning of the child and refraining from laying the child down directly after meal times.

Recurrent episodes of GERD can be very harmful for children, and nutritional strategies should be adapted accordingly. Children with cerebral palsy (CP) are at an increased risk of developing GERD due to complications such as decreased lower esophageal sphincter tone, delayed gastric emptying, impaired esophageal motility, poor posture, recurrent seizures, scoliosis and various medications.3



  1. Penagini F et al. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients. 2015;7(11):9400-15.
  2. Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. Dev Disabil Res Rev. 2008;14(2):128-36.
  3. Kim S et al. Gastroesophageal Reflux in Neurologically Impaired Children: What Are the Risk Factors? Gut Liver. 2017;Mar15;11(2):232-36.

A child with cerebral palsy (CP) may also be experiencing associated conditions, such as:


Up to 74% of children with severe disabilities experience constipation.1
Contributing factors are:1

  • Reduced fluid and fibre intake
  • Abnormal bowel mobility
  • Prolonged immobility
  • Skeletal abnormalities
  • Generalized hypotonia (decreased muscle tone)

Recurrent episodes of constipation can lead to chronic nausea, recurrent vomiting, abdominal pain and, ultimately, reduced food intake.1 A child experiencing constipation might refuse to eat due to abdominal pain and may not get the required nutrition for proper growth and development.1


In certain cases of very limited mobility, children with CP are at an increased risk of obesity.

Overweight children that have a BMI (body mass index) greater than the 95th percentile are at an increased risk of obesity and need to follow an individualized nutritional plan.

It is important to diagnose and treat these associated conditions while managing CP-related challenges. Specific nutritional solutions are an essential part of an overall holistic treatment plan.



  1. Penagini F et al. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients. 2015;7(11):9400-15.