INTRODUCTION

Technological and medical development over the last three decades increased the survival chances of pre-term and low weight babies, creating new challenges for the professionals that work with these babies. Some of these children present neurological disorders due to problems at birth such as cerebral palsy1.

It is known that from 39% to 56% of the children with chronic developmental disorders, such as cerebral palsy, will have swallowing disorders2. The consequences of such disorders will be new health problems that in turn will worsen global conditions of these patients and their ability to adapt to society.

The basic motor difficulty of these children may affect the oral motor function (OMF), that is, the motor and sensorial aspects of the structures of the oral cavity and pharynx until the opening of the esophagus3. Therefore, we know that these children are part of a risk group to develop swallowing or dysphagia disorders that can be noticed as the first symptoms of neurological disorders. The oral motor function disorders may generate an array of disabilities in each step of the swallowing process with potential for simultaneous interactions. A significant number of children with chronic changes of swallowing presented malnutrition, dehydration, aspiration and pneumonia.

Generally symptoms reported in these cases were regurgitation, difficulty in swallowing their own saliva, cough during feeding time and respiratory instability or apnea These were among others that may generate aversion to eating certain foods, excessive time spent with the feeding process and the need for a special diet, different from that followed by the rest of the family. These symptoms eventually generate tension and anxiety in parents, and they make the eating process difficult, tiresome and not very pleasant.

The few short-term studies on life expectancy of patients with cerebral palsy suggested that the key aspects to define life expectancy of such patients are severe mental retardation and reduced body mobility, in addition to feeding difficulty.

The use of specific techniques to establish a clear diagnosis of the swallowing disorders help to develop the treatment protocols that are creative and realistic. The observation of swallowing function helps to estimate a healthy development and better quality of life for children with cerebral palsy.

In view of the importance of feeding to individuals and of the difficulty that children with cerebral palsy may have to swallow, this study has the objective to typify swallowing patterns of children with cerebral palsy, comparing them to normal children, correlating all aspects related to level of oral motor dysfunction, quadriplegia and food consistency with time spent in swallowing.

MATERIAL and METHOD

This study was carried out in two groups of children (1 to 5 years of age) living in the city of Curitiba. One group (GI) with 57 children having cerebral palsy referred from specials schools and the other (GII) with 19 children without neurological disorders, students of a normal school. Twenty-seven out of 57 children of the GI group were female and 30 male. The GII group was formed by 19 children, 10 were male and 9 female.

The group of children with cerebral palsy had 32 with quadriplegia, 15 with diplegia and 10 with hemiplegia. The children with diplegia and hemiplegia (n=35) were all spastic. In 32 quadriplegic subjects, 62.5% (n=20) were spastic; 9.3% (n=3) had athetosis; 6.2% (n=2) lacked muscular tone and 21.8% (n=7) had a combined type of cerebral palsy. The level of involvement ranged from mild to severe.

A protocol to assess swallowing patterns was used to carry out the examinations. This protocol was applied to all children under the same conditions, carefully taking into account the natural feeding time of the children, ensuring that they were hungry to prevent outcome distortions. The children were placed in sitting position on adapted chairs, if needed, in order to make them feel comfortable and in a stabilized position. Some children had additional help from their teacher to control their posture. A small group of children needed to be fed on the lap, due to the presence of primitive reflexes. This was the only way to comfortably accommodate them for feeding.

The material for the use of the protocol was chosen as follows: 100 ml of orange juice (liquid food), 140 grams of homogenized strawberry yogurt without pieces of fruit (paste) and 12 grams of Chocolate stuffed cracker (solid food). These foods were totally swallowed and in the order presented. The test included the use of a chronometer, brand Technos, with minutes and seconds displays to measure swallowing times for each kind of food.

The investigation protocol included the identification and result of the observation in the presence of seven behaviors related to the oral motor function (OMF), namely: biting reflex, control of the lips, sialorrhea, ability to suck the liquid from the glass, ability to take the paste food from the spoon, mastication and food conduction and the time spent in swallowing each one of the three food consistencies analyzed.

A rating system was designed to analyze the results obtained, with 1 for the behaviors viewed as more matured, or 0 for the behaviors viewed as more immature. This rating system was applied to each one of the 7 items of OMF (Chart 1).

Each child received a final score that corresponded to the sum of the values of the seven items of OMF, thus the score ranged from 0 to 7 expressing the performance of each child for OMF. The closer the total score was to 7, the more normal the child was.

The swallowing time spent was recorded for each one of the three types of food after the introduction of the first portion of it in the mouth until its complete emptying in the last swallowing. Mean times to swallow each food were compared between the two groups and the influence of quadriplegia. Children were regrouped according to the level of oral motor dysfunction - mild, moderate, severe or profound and normal OMF. Each one of the groups had the mean swallowing time spent recorded for each of the food consistencies studied; thus the influence of oral motor dysfunction (OMD) was analyzed in the swallowing times. Finally, the three food consistencies were correlated to swallowing times.

Data were analyzed by means of software Sphinx Lexica version 209K in statistics to obtain the percentage and variables cross over.

RESULTS

The first analysis compared each one of the 7 items of oral motor function (OMF) between the two groups, trying to obtain the functioning pattern of the groups and to observe their differences. Next the children of the GI group were divided into functional groups according to the level of oral motor dysfunction (OMD). The swallowing times were associated to normal OMF, mild, moderate, severe, and profoundly compromised.

Differences could be noted in the occurrence of the seven items of OMF observed in the groups and none of the items of the two groups were equivalent. The ability to control the lips preventing leakage of the food bolus out of the oral cavity during swallowing was the item that had increased difference between GI and GII in terms of occurrence. The ability to swallow the liquid from the glass was the aspect that approximated the two groups (Table1).

The more matured abilities were reported with lower frequency in children with quadriplegia and the behaviors considered as more matured were less frequent. All children with biting reflex had quadriplegia.

Normal swallowing occurred in association with lack of biting reflex in 93% of cases, the presence of ability to suck in the liquid from the glass occurred in 90%, the ability to take the food from the spoon in 79% and the ability to masticate the food in 86%. The abnormal conduction occurred associated to the absence of lip control in 96% of the cases and the presence of sialorrhea in 93%. Ninety percent (90%) of the children with abnormal swallowing (requiring posture or facilitating maneuvers) had quadriplegia. (Table 2).

The classification of OMF of children in groups GI and GII is presented below, according to score given to each item of the OMF. In GI group, 23% of the children had normal OMF, whereas this index was of 100% in the GII group. Thus, 77% of children reported some level of oral motor dysfunction in the GI group, ranging from mild to profound.

The relations between OMF and swallowing time are presented in Table 3 and they showed that the greater the oral motor dysfunction, the greater is the time spent to carry out swallowing in each one of the three consistencies of food, suggesting that OMD and swallowing time are directly related.



In the GI group, 30% of the children presented motor oral dysfunction ranging from deep (18%) to severe (12%), and all had quadriplegia. Therefore, children with quadriplegia took longer to swallow the food. Out of the thirty-two children with quadriplegia, 53.1% (n=17) had motor oral dysfunction that ranged from severe to profound.

As to consistency of food and swallowing times, the children of the GI group with profound OMF took 14.2 times more to swallow liquid foods and 6.4 times more for paste food than that of the children of the GII group. None of the children with deep oral motor dysfunction swallowed the food with solid consistency. Among the children with severe oral motor dysfunction only 30% (n=3) swallowed solid food, and they took 4.9 times more to swallow solid food than the children from GII group. Swallowing times were closer between the two groups in relation to paste foods. The liquid food was the type of food that had greater difference of mean times of swallowing between the studied groups. The solid food was the least swallowed (Table 3).



DISCUSSION

Nutritional issues are the current challenge for those working with children with cerebral palsy; in addition, understanding of the health condition of these children is required. The scientific literature shows a trend towards interdisciplinary care in cases of swallowing disorders. The integration with other professionals such as nutritionists, gastroenterologist, endoscopic radiologist, pediatrician and physiotherapist, among others, make us think about the role of the speech therapist in those interdisciplinary teams.

The speech therapist should address the issue of patients' health from a global perspective, observing the oral motor functioning for good nutrition and hydration of the child that is under his/her care. In other words, it is to have a functional view of swallowing, observing the motor ability to transport the food boluses and the efficiency to maintain the child's good nutrition and to help his/her development, which is the main goal of this process.

This study was developed within this view, to discuss issues related to swallowing time of these children and, ultimately, to reflect on the real time spent by them during daily meals. The importance of such questionings is based on the need for a realistic and straightforward view to be advocated as the best procedure and management of feeding process in these children.

The qualitative analysis of swallowing has been studied by several authors with respect to posture and movement changes on the ability to reduce, form and propel the food boluses, as well as premature leakage, penetration and aspiration of food in the airways, among others. These studies are clinically highly useful, since they provide theoretical ground for the daily practice with patients that suffer from similar disorders.

Quantitative parameters, such as transportation time of the bolus in each step of the process and the time spent with meals, may be also equally important parameters4,5,6.

The quantitative analysis should be considered especially for children with oral motor dysfunction associated with malnutrition, linear growth, weight loss or low immunity, among others. The use of food with easy-to-swallow consistency should be advocated in these cases before other more invasive techniques are required, such as for example gastrostomy7,8,9,10.

It was noticed that having an idea of the amount of time spent by the family to feed their children is a key aspect to make decisions about the kinds of food consistency that are more indicated for each child, the way to feed him/her and feeding frequency11,12,13 Former studies had already reported that families tend to spend increasingly less time than that required to feed these children, which contributes to decreasing the amount of food swallowed and usually increases malnutrition and poor hydration14,15.

The observation of abnormal reflex activity and sialorrhea has been the subject of several studies on swallowing disorders in children with cerebral palsy, since it causes OMF disruption and mirrors the immature functioning of the stomatognathic system. Therefore, the ability to retain the food bolus, suck in liquids, take the food from the spoon, masticate and swallow are normally strictly related to the specialization of the movements in the aerodigestive tract, the development of the stomatognathic system and the maturing of central nervous system. These abilities make it possible to ensure good nutrition and growth of individuals3,16. For this reason, this study chose to analyze these aspects of the OMF.

Several authors, under different perspectives, have reported the changes in swallowing of subjects with multiple compromises. Reilly et al (1996)2 reported in their study that 38% of their studied subjects had swallowing changes. Still in our study, we observed that 49% of the patients in the GI group were not able to carry out normal conduction of food, whereas all children of the GII group were. The differences were due to the fact that the authors raised swallowing difficulties related only to the first year of life of the sampled group. Lanert & Ekberg (1995)13 reported poor propulsion, especially in patients with quadriplegia. Likewise, in our study there was correlation between conduction changes and quadriplegia since 90% of children with conduction changes had quadriplegia. Wrigth et al (1996)17 studied the children with severe cerebral palsy and found 75% of the children with delayed swallowing reflex. Park et al, (1992);18 Tawfiik et al (1997)19 associated conduction difficulties to the need for gastrostomy as a resource to ensure the health of such children.

Some important correlations were made between the behaviors observed. A more matured ability is generally followed by others. The correlation between normal swallowing and the high percentage of children with absence of biting reflex, ability to take the food from the spoon, ability to suck in liquid from the glass and the possibility to masticate may provide important supporting material to therapeutic practice. The prescription of treatment programs encouraging the development of these abilities will lead to quantitative and qualitative improvements of swallowing process of these children, improving their nutritional condition and quality of life.

The population with cerebral palsy presented varied functioning of swallowing and children with quadriplegia are those that demand higher attention. The efforts to provide conditions of normal development of oral functioning for this group, or in other words, the attempt to lead these children from immature feeding (paste and homogeneous diet) to mature feeding (heterogeneous and solid diet) should include careful continuous assessment of good health conditions.

In the studied sample of patients with cerebral palsy 77% presented oral motor dysfunction. In the GI group of children 30% had severe or profound oral motor dysfunction. Our findings were similar to those of Reilly et al (1996)2 who found that 36.2% of the studied children had severe oral motor dysfunction and 90% of their sample had some level of oral motor dysfunction. The difference from 90% to 75% is likely to be due to the fact that 70% of Reilly's sample had severe or profound cerebral palsy, whereas in our sample only 66% of the children had moderate to severe cerebral palsy.

Moderate or severe oral motor dysfunction was associated to quadriplegia. These data were similar to those reported by Reilly et al (1996)2. In the group of patients with quadriplegia, 97% presented oral motor dysfunction, similarly to the outcomes of Morton et al (1993)11 who referred that 100% of their group of patients with quadriplegia had oral motor dysfunction, and to Wrigth et al (1996)17 that reported 97%. Still, data of our study suggested that the greater the oral motor dysfunction, the higher is the time spent in feeding those children, as mentioned by Jones (1989)14; Morton et al (1993); Arvedson (1993)3; Schuberth (1994); Lanert & Ekberg (1995)13 and Buchholz (1997)20. In this context, our group of children with quadriplegia had higher level of oral motor dysfunction and, therefore, the group that took the longest to swallow foods was the one that spent more time in the feeding process.

The outcomes of our study indicated the existence of a major difference between the time spent to feed children without neurological disorders and children with cerebral palsy, particularly children with quadriplegia. We found out that the children with cerebral palsy may take up to 14.2 times more to swallow comparatively to the group without neurological disorders. Lanert & Ekberg (1995)13 found a very similar piece of data to ours and stated that children may spend up to 15 times more time and take up to 7 hours to be fed. Jones (1989)14 stated that some children might spend from 4 to 6 hours in this activity. This fact may generate frustration and stress for those families that need to face the difficulty of feeding such children, which in turn will lead to reduction of food offer and malnutrition.

Among the three consistencies studied, the liquid food was the one that had the greatest differences of swallowing time between the groups and paste food had the lowest level of differences. Swallowing of solid food was less frequent than that of other consistencies, but when present, the difference between the times spent by the two groups was lower than the time spent with liquid foods. Other investigators reported these differences. Gisel et al (1995)21 adverted that paste consistency should be considered for children with oral motor dysfunction and malnutrition, since it is easier to be handled and may reduce cough and aspiration, facilitating feeding and nourishing the child. Helfrich-Miller et al (1986)22 indicated the use of solid food, associated to oral motor stimulation to treat children with cerebral palsy, with the purpose of multiple swallowing to decrease the time of pharyngeal transit, decrease residues and the need for multiple swallowing to clean pharynx content.

The results of the present study suggested the need for monitoring children with cerebral palsy, particularly those with quadriplegia, regarding issues of swallowing and nutrition. The amount of time spent during meals, the reduced amount of food, oral motor dysfunction, the growth and increase of energy expenditure, may contribute to development stagnation and damage to the child's global development.

CONCLUSION

The use of an assessment protocol for the swallowing patterns in a group of children, 57 with cerebral palsy and 19 without any neurological disorders, led to the following conclusions: The greater the level of oral motor dysfunction, the greater is the time spent to swallow food in the three food consistencies studied. The swallowing time of the group with cerebral palsy was up to 14.2 times higher than that of the normal group. In the three consistencies studied, liquid food was the one that outlined the most the normal group. In terms of swallowing time, paste food had the least difference between the groups and solid food was the less frequently swallowed food in the group with cerebral palsy. The group with quadriplegia was the one with poorer performance in terms of OMF and food swallowing time. Therefore, they require more attention regarding swallowing issues.

Acknowledgements

We would like to acknowledge the school Vivian Marçal, Associação Paranaense de Reabilitação - APR (Parana Rehabilitation Association), the Rehabilitation Clinic of Pedro Seleme Foundation that permitted the use of their facilities for the application of the Research Protocol, and the families and the children involved in this study for their kindness in participating in this research.

REFERENCES

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1 Master Degree in Human Communication Disorders.
2 Ph.D. in Human Communication Disorders.
3 Ph.D. in Surgery.

Affiliation: Universidade Tuiuti do Paraná

Address correspondence to: Sandra Regina Vasconcelos - R. Verônica Szeremeta, 23 - São Brás Curitiba - PR - CEP 82320-410 - Tel: (55 41) 272-6792 or (55 41) 9977-3129 - E-mail: jlvasco@uol.com.br

Presented as Free Communication in the III Reunião Brasileira de Disfagia.

Article submitted on November 30, 2001. Article accepted on December 21, 2001.