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Research Review - Final – Mar. 20, 2013
Interventions for Feeding and Nutrition in Cerebral Palsy
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Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.
The Vanderbilt Evidence-based Practice Center examined the effects of available interventions for feeding and nutrition problems that have been evaluated in individuals with cerebral palsy (CP).
MEDLINE® via the PubMed® interface, PsycINFO® (psychology and psychiatry literature), the Educational Resources Information Clearinghousesm, OTSeeker, REHABDATA, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL®) database. Additional studies were identified from reference lists and technical experts.
We reviewed studies providing effectiveness data for feeding interventions in populations of any age with CP. We included studies focused on nonsurgical and surgical interventions for feeding and nutrition difficulties. Nonsurgical interventions included positioning, oral appliances, oral stimulation, sensorimotor facilitation, and caregiver training. Surgical interventions included gastrostomy or jejunostomy tubes and fundoplication. We assessed both intermediate/surrogate and patient-centered/health outcomes.
Fifteen articles (comprising 13 unique studies) met our inclusion criteria. One good quality systematic review on behavioral interventions for feeding issues in individuals with cerebral palsy was published in 2011 and is updated with one additional study on caregiver education in this review. The existing review included 21 studies with conflicting results related to the effects of sensorimotor interventions on short-term improvements in feeding. Eleven studies (nine case series) of surgical interventions met our inclusion criteria. These studies included 309 children. In all nine studies of gastrostomy (with or without fundoplication), gastrostomy-fed children gained weight. Baseline weight z-scores ranged from ?3.56 to ?0.39; followup z-scores ranged from ?2.63 to ?0.33, relative to typically developing populations. Two studies assessed fundoplication for reflux: in one RCT both Nissen fundoplication and vertical gastric plication reduced reflux (reduction in symptoms of 57% and 43%, respectively), while in one case series, reflux recurred within 12-months postfundoplication in 30 percent of children. The highest rates of reported harms in any study were minor site infection (59%), formation of granulation tissue (42%), gastric leakage, recurrent reflux (30%), and aspiration and pneumonia (29%). Even though the reported death rates ranged from 7 percent to 29 percent, the underlying cause of death was most likely not due to the surgical treatment.
Evidence for behavioral interventions for feeding disorders in CP consists of mostly small, short-term, pre-post studies, with strength of evidence ranging from insufficient to moderate. Some studies suggest that interventions such as oral appliances may enhance oral sensorimotor skills, but there is a clear need for rigorous, comparative studies. Evidence for surgical interventions is insufficient to low. All studies to date demonstrate significant weight gain with gastrostomy. Results for other growth measures are mixed, and substantial numbers of children remained underweight, although given a lack of appropriate reference standards for the CP population, these results should be interpreted cautiously. Longer term, comprehensive case series are needed, as are prospective cohort studies. More research is needed to understand potential harms in the context of benefits and potential risks of not treating.