Introduction

Cerebral Palsy (CP) is a neurological disorder. It is caused by an injury to the developing brain, occurring before, during or shortly after birth. CP affects an individual’s movement, muscle tone and can affect their ability to maintain balance and posture. Symptoms of CP vary from person to person. Some individuals with CP may have a higher risk of visual and hearing impairment, digestive problems, a poor swallow, urinary problems, sensory issues and chronic pain.

Nutritional issues with cerebral palsy and the role of the Dietitian

To ensure optimal growth in childhood and to support healthy muscle and bone development across the lifespan, an individual with CP should enjoy a balanced and varied diet.

However, as CP is a highly varied condition and as nutritional needs change throughout childhood, adolescence and into adulthood, regular assessment, advice and support from a Dietitian is recommended.

A broad spectrum of nutritional complications are associated with CP and these may impact an individual’s risk of developing poor nutrition. These complications and their impacts are discussed below.

Feeding, Eating, Drinking and Swallowing (FEDS)

Many individuals with CP experience Feeding, Eating, Drinking and Swallowing (FEDS) difficulties due to reduced muscle function. This can result in challenges holding or using feeding utensils, difficulties managing food and fluid in the mouth (oro-motor problems) and swallowing difficulties.

FEDS difficulties can include:

• Lengthy meal times which are more effortful for the individual
• Food and fluid entering the lungs (aspiration) which can result in chest infections
• Problems using standard utensils such as spoons, forks and cups

Based on an individual’s specific difficulty, recommendations may include:

• Adjusting feeding/meal pattern, g. eating ‘little & often’ in place of larger meals
• Supplementing the diet to increase its nutritional value
• Modifying the texture of foods and/or fluids to make them safer to swallow
• Adjusting seating and positioning
• Introducing adapted utensils g. cup with a lid; weighted utensils
• Obtaining nutrition via a feeding tube g. gastrostomy tube

When managing FEDS difficulties, a healthcare professional such as a Doctor, Dietitian, Speech & Language Therapist and Occupational Therapist can assess and advise on how to manage any difficulties experienced. Support from a Dietitian will be important if a texture modified diet has been recommended (e.g. pureed, soft foods, thickened fluids). A Dietitian may advise on food fortification (i.e. the addition of extra calories/protein to foods to increase the nutritional content of foods) and may also suggest appropriate oral nutritional supplements which can help to maintain weight. See www.nutritionsupports.hse.ie for advice on food fortification (adults).

Gastrointestinal Problems

Digestive problems are common in individuals with CP and can impact a person’s nutritional intake.

Common problems can include:

• Gastro-oesophageal reflux
• Constipation

Gastro-oesophageal reflux occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach (oesophagus). This can cause pain, and can impact an individual’s food and fluid intake. Diagnosis and treatment should be discussed with your Consultant or GP. A Dietitian can advise on dietary changes to help improve symptoms.

Management strategies can include:

• Adjusting feeding/meal pattern g. eating ‘little & often’ in place of larger meals
• Avoiding trigger foods g. spicy foods; fizzy drinks
• Considering feeding position g. upright position during and after meals
• Maintaining a healthy weight

Constipation is a common problem for individuals with CP and is caused in part by reduced fibre intake, poor fluid intake, hypotonia (low muscle tone), reduced levels of activity and certain medications.

Management strategies can include:

• Increasing fibre containing foods, g. wholemeal bread, wholegrain breakfast cereals, wholemeal pasta/rice, beans, legumes, fruit and vegetables.
• Increasing fluid intake
• Incorporating physical activity where possible (advice from a Physiotherapist may be helpful)
• Review of medications with your GP or Consultant

A Dietitian can provide tailored advice on how to incorporate more fibre and fluids into the diet. This can be especially challenging when a modified texture diet has been recommended.

Weight Management

 Some children and adults with CP may be prone to excessive weight gain. This may be due to reduced physical activity or lower than typical energy requirements. Gaining too much weight can be avoided by reducing intake of foods that are high in fat and sugar and sugary drinks. The HSE’s food pyramid provides information on typical portions sizes for children and adults www.hse.ie. Increasing activity levels, where possible, will also help to maintain a healthy weight. If nutrition is being provided via a feeding tube, a Dietitian can advise on how to adjust the feed to ensure optimal weight gain.

Tooth Decay

Children and adults with CP are prone to tooth decay. Bacterial plaque can form on teeth exposed to a considerable amount of acid (gastro-oesophageal reflux), in those who experience difficulties with saliva management or difficulties swallowing and chewing.

Strategies to promote good dental/oral health include:

• Brushing teeth at least twice daily, particularly before bedtime
• Avoiding excess sugary foods and drinks
• Regular attendance with the dentist for assessment, monitoring and support

Osteopenia/Osteoporosis

 Osteoporosis is a condition that affects the inside of your bones, making them fragile. Osteopenia is the early stage of Osteoporosis. Increased bone fragility can lead to a higher risk of breaking a bone (fracture).

Many factors associated with CP are also associated with increased bone fragility. These include immobility, poor nutrition, and the side effects of some medications.

Recommendations for maintaining good bone health include:

• Ensuring the diet contains good sources of Calcium rich foods. These include milk, cheese, yoghurts, milk puddings, tinned fish and sesame seeds/paste.
• Ensuring adequate vitamin D Vitamin D is found in egg yolk, liver, oily fish, fortified milk or spreads. However, most of our Vitamin D is made through the action of sunlight on the skin, therefore some exposure to sunlight (15-20-minutes between the months of May- September) is also recommended. See www.hse.ie for advice on sun safety.
• Incorporating weight bearing activities into the daily routine (e.g. using a standing frame). A physiotherapist can advise on a weight bearing programme.
• Discussion with your Dietitian, Consultant and GP about how to optimise bone

If you require further information about Cerebral Palsy and nutrition, or for a referral to a Dietitian, please contact your GP, Paediatrician/Physician, or the Irish Nutrition and Dietetic Institute (INDI) at www.indi.ie.

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