ASSOCIATIVE AND CO-MITIGATING FACTORS

GASTROINTESTINAL, NUTRITIONAL AND DIETARY

Most children with cerebral palsy are at risk for secondary undernourishment due to feeding difficulties and oromotor dysfunction. Oromotor dysfunction is the inability to control muscles in the mouth required for proper food intake levels. Children with cerebral palsy can benefit from feeding and nutrition assessments.

A study published July 1, 1999 by Elsevier titled “Gastrointestinal manifestations in children with cerebral palsy” found the majority (92%) of those with cerebral palsy had one or more significant gastrointestinal symptoms, including swallowing disorders, regurgitation, abdominal pain, chronic pulmonary aspiration, and chronic constipation.

Elsevier also found 93% of those with swallowing disorders had oral dysfunction and/or pharyngeal phase swallowing difficulties. Swallowing occurs in three phases. Difficulties in swallowing can occur at one or more of the phases:

  • Oral phase – food is placed in the mouth, moistened and chewed to proportionally size the food for passage to the pharynx.
  • Pharyngeal phase – sensory receptors activate involuntary and rhythmic contractions that push the food from the pharynx to the esophagus. The larynx temporarily inhibits breathing to protect the lungs.
  • Esophageal phase – food progresses from the esophagus to the stomach through rhythmic contractions. Esophageal sphincters open and close to provide physical barriers to avoid regurgitation.

Nutrition Assessment is Beneficial
for Identifying Digestive Dysfunction

In a study published March 3, 2000 in Developmental Medicine & Child Neurology by Department of Paediatrics at the University of Oxford in the United Kingdom found feeding problems are common and severe, particularly among those with neurological impairment – yet only 64% of the children had undergone feeding and nutrition assessment. Of the parents of children with oromotor dysfunction who responded to the survey, 93% had children diagnosed with cerebral palsy. Of the children with gastrointestinal problems:

  • 59% were constipated
  • 22% had significant problems with vomiting
  • 31% had at least one chest infection within a six month period
  • 89% needed assistance with feeding
  • 56% choked with food
  • 28% had prolonged feeding times

Other associative conditions may include recurrent vomiting, chronic pulmonary aspiration, diarrhea, choking, pneumonia, and flatulence.

Feeding difficulties may lead to less than ideal food intake, causing undernourishment, failure to thrive, malnutrition, growth delay, and gastroenterological conditions. Intestinal dysmotility, delayed gastric emptying, and reflux may lead to an increased risk of food aspiration and pneumonia.

Oromotor dysfunction also causes speech, drooling, sucking, chewing, and swallowing difficulties and can lead to a significant increase in the length of time required for feeding. As a result, many children with cerebral palsy are on liquid and semi- solid foods. Some are tube fed, while others may be prescribed a combination of food and tube feedings.

Focus Treatment on Proper Nourishment

The focus of treatment is to prevent or treat undernourishment, while improving oromotor skills. To do so, a multi-disciplinary team of clinical dietitians, nurses, feeding therapists (occupational therapist, speech/language pathologist or physiotherapy), pediatricians, radiologists, pediatric dentists, neurologists and otorhinolaryngologists (ear, nose and throat specialist) may be called upon to assess, formulate, manage, and monitor the child’s dietary intake and ability to consume. The experts required will depend on the severity of the child’s condition, the problems experienced, and the discretion of the child’s primary care physician.

Monitor Gastrointestinal Health with Imaging Technology

CT scans or magnetic resonance imaging (MRI) may be ordered to assess gastrointestinal health and aspiration. Intraesophageal pH can be monitored or an upper GI endoscopy may be required to determine reflux and vomiting disorders. Eating ability and nutritional needs can be evaluated. Body mass index and fat-free mass can be compared to the child’s age, height, weight and form of cerebral palsy to gauge growth and developmental level. The length of time for feeding and the severity of impairment will help determine feeding strategy.

Improve Nutritional Status through Nutritional Interventions and Rehabilitation

The multi-disciplinary team of experts are likely to recommend timely rehabilitation and nutritional interventions to improve nutritional status and quality-of-life. Nutritional interventions may include increasing the quality of food, increasing fluid intake, and forming individualized meal plans with specified quantities and consistencies of food. High energy nutrition supplements may be required. Medications (prokinetic drugs, antacids and gastric enzyme inhibitors) may be prescribed.

Therapy may improve head control, feeding skills, and speech. Surgeries and feeding tube options may be considered, including:

  • nasoeteric (enteric)
  • pecutaneous endoscopic gastrostomy (PEG)
  • gastrojejunal (GJ tube)

Feeding technique instruction can improve feeding mechanics.

Gastrointestinal, nutritional and dietary conditions include:

  • Abdominal pain
  • Aspiration
  • Bladder control
  • Bowel (intestinal) obstruction
  • Bowel incontinence
  • Chewing difficulties
  • Choking
  • Chronic pulmonary aspiration
  • Constipation
  • Delayed gastric emptying
  • Delayed growth and development
  • Dental caries/tooth decay
  • Diarrhea
  • Drooling
  • Enuresis (bed wetting)
  • Esophageal bleeding
  • Esophagitis
  • Failure to thrive
  • Feeding difficulties
  • Flatulence
  • Gastroesophageal disease
  • Gastroesophageal reflux (GERD)
  • Gastrointestinal motility
  • Gastrointestinal tract bleeding
  • Genitourinary problems
  • Growth impairment (maturation)
  • Halitosis
  • Immobilization
  • Inadequate oral intake
  • Incontinence
  • Intestinal dysmotility
  • Irritable bowel syndrome
  • Malnutrition
  • Obesity and weight management
  • Oromotor dysfunction
  • Pneumonia
  • Primary intestinal pseudo obstruction
  • Prolonged colonic transit
  • Pseudobulbar palsy
  • Sucking difficulties
  • Swallowing difficulties
  • Undernourishment
  • Urinary incontinence
  • Urinary tract infections
  • Vitamin deficiency
  • Vomiting

Every Child’s Condition Is Unique

The list of possible primary, secondary, and associative conditions, as well as co-mitigating factors, can be grouped into categories, but not all conditions will be experienced by an individual with cerebral palsy. Some may encounter conditions not listed, as well.

Cerebral palsy can take a mild, moderate, or severe form depending on a host of factors. The type, location, and extent of impairment are considered, as well as any associative conditions and co-mitigating factors, when creating a treatment plan. Over the course of the person’s life, he or she may encounter any number of associative or co-mitigating factors.

Cerebral palsy is non-progressive, meaning the brain injury or malformation will not progress in severity. However, secondary conditions resulting from the brain damage may develop and change over time. For example, brain injury can cause facial muscle impairment which doesn’t change over time. Chewing, swallowing and aspiration can occur when facial muscles are impaired. Aspiration can lead to pneumonia, and pneumonia is a health condition that can become worse or better over time.

Impairments can change with – or without – proper management. As a person ages, the muscular-skeletal structure may age prematurely depending on postural conditions, care, treatment and therapy. Other health conditions or life circumstances may also affect the individual’s condition over time. These can include access to health care, health insurance benefits, exposure to toxins, new health conditions, socialization, exercise, and traumatic accidents or events.

MyChild™ lists the possibilities in hope of providing families with a better understanding of the types of conditions – and categories of conditions – an individual with cerebral palsy may encounter over their lifespan. An overview of the different types of professionals likely to treat these conditions is also contained here. It should be noted that MyChild™ does not dispense medical advice. Any conditions your child may experience should be discussed with his or her medical team for proper diagnosis and treatment. In the case of emergencies, contact 911 immediately.

ASSOCIATIVE CONDITIONS AND CO-MITIGATING FACTORS Proper Terminology

Because the terminology used is so specific, yet remarkably similar, terms such as primary, secondary, associative and co-mitigating conditions are used interchangeably, yet incorrectly. It is helpful to know the difference between the terms when attempting to understand cerebral palsy.

Primary condition - These are a direct result of the brain lesion or brain malformation. Primary conditions affect motor coordination, motor control, muscle tone, posture and balance. Gross motor, fine motor, and oromotor functioning are also considered primary conditions of cerebral palsy.

Secondary condition - Primary conditions, in turn, may lead to secondary conditions such as inability to chew, inability to swallow, breathing difficulties, bladder and bowel control issues, and communication difficulties. If the brain lesion or malformation that caused cerebral palsy did not exist, these secondary conditions would not be present.

Associative conditions - Research has shown that individuals with cerebral palsy often have associative conditions not caused by the same brain injury or malformation which caused cerebral palsy, but proven to be common with individuals who have cerebral palsy. If the brain injury or malformation that caused the cerebral palsy did not occur, these conditions may still be present in the individual. Associative conditions include intellectual impairment, epileptic seizures, hearing impairment, and vision impairment.

Co-mitigating factors - An individual may also have health conditions separate from cerebral palsy. Unlike associative conditions, researchers have not concluded that these conditions have a high correlation to cerebral palsy. Co-mitigating factors exist regardless of cerebral palsy. Examples of co-mitigating conditions of cerebral palsy include autism, attention deficit hyperactivity disorder (ADHD), and asthma.

Associative Conditions and Co-Mitigating Factors

There are eight major categories of associative conditions and co-mitigating factors. To learn more about them, click one of the following: