Paediatric Feeding (Disability) Group “In Children with Cerebral Palsy (Spastic Quadriplegia), what is the evidence that upright positioning in midline is safest for eating and drinking?”

Reason for Clinical Question We aimed to gather the evidence behind our recommendations that being upright is the ideal position for clients with Cerebral Palsy. Our search is still going….here is the evidence so far

Evidence Thus Far Level of Evidence#Source of Evidence Level 1 Evidence0 ERIC Google Scholar Medline PubMED OVID CINAHL PEDro SpeechBite Level 2 Evidence0 Level 3 Evidence0 Level 4 Evidence3

Difficulties with Articles We found a significant number of articles just stating information from different literature sources rather than critiquing the research resulting in these articles not falling in the levels of evidence required for the CAT/CAP

CAP Evidence Summary What we found so far… Giselle et al (2003). Feeding Management of Children with Severe Cerebral Palsy and Eating Impairment: An Exploratory Study The study subjects were children with Cerebral Palsy with severe motor impairment and spastic tetraparesis Procedures in this study used videofluoroscopy in a 90 degree (upright), 20 degree, 30 degree and 45 degree reclined positions. Best positions found for individuals were between 20 to 30 degrees reclined rather than 90 degrees upright. There were some improvements in pulmonary function, which may be attributed to change of consistency/positioning/ therapy of GOR

CAP Evidence Summary Hulme et al (1987). Effects of Adaptive Seating Devices on the Eating and Drinking of Children with Multiple Handicaps. The study used subjects with a variety of tonal difficulties (i.e. spastic, hypotonic, mixed) Adaptive Seating has a positive outcome on feeding when the child with cerebral palsy is positioned with their feet, knees, hips, trunk and head in alignment. Didn’t mention anything about upright, reclined or tilted positioning.

CAP Evidence Summary Larnert & Ekberg (1995). Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Subjects were all children with tetraplegia and dystonia. All had cerebral palsy. The procedure was videoradiographic examinations (MBS) Bottom line is that a 30 degree reclined position with neck flexion is the safest positioning for feeding a child with tetraplegia and dystonia.

Summary to date … Reclined, 30 degree position has evidence that it is better than upright, 90 degree position for most children with cerebral palsy. Positioning is highly individualised for a child with cerebral palsy so this may not work for everyone. Most importantly hips, head and trunk alignment has the biggest impact on feeding skills for a child with cerebral palsy.

Clinical Implications for a child with severe cerebral palsy Research evidence Patient values and goals Clinical Experience Therapist recommending upright positioning for feeding Parent wants their child with cerebral palsy to be fed orally EBP Research so far indicating that 30 degree reclined positioning is best

Thanks to… Dr Bernice Mathisen (our academic contact) Meily Choi Nitha Thomson Carolyn Ryan Sudi Veerabangsa Dorothea Gray Jenny Wood Helen McLaren Katrina Mulready And those Speech Pathologists who attended occasionally to help along the way

Next Year in 2009… We will complete our CAT once all articles have been reviewed So come and help us complete our CAT by: –Contacting Nitha Thomson or Carolyn Ryan and joining our EBP group – –Phone: (Nitha) (Carolyn)

References Larnert G, & Ekberg O (1995) Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Acta Paediatr Jun;84(6): Hulme JB, Shaver J, Acher S, Mullette L, & Eggert C (1987) Effects of adaptive seating devices on the eating and drinking of children with multiple handicaps. American Journal of Occupational Therapy 41(2):81-9 Giselle EG, Tessler MJ, Laplerre G, Seidman E, Drouin E, & Fillon G (2003) Feeding management of children with severe cerebral palsy and eating impairment: an exploratory study. Physical and Occupational Therapy in Pediatrics 23(2): 19-44