Brain Disorders/Neurological

The Importance of Postural Control for Feeding

Fran Redstone; Joyce F. West

Abstract and Introduction

Abstract

Children with cerebral palsy and other neurodisabilities often have decreased postural control that
exacerbates their feeding/swallowing disorders. Correct postural alignment is important in the normal
feeding/swallowing process. In the child with cerebral palsy, the alignment and stability of the oral
structures for feeding/swallowing may be compromised by abnormal muscle tone and movement
patterns. Effective oral functioning for feeding begins with attaining better head stability to improve jaw
control. Head control is influenced by trunk alignment, which depends upon the stability of the pelvic area.
Techniques such as therapeutic seating and oral control can enhance postural alignment and improve
oral functioning for the safe intake of food.

Introduction

The pediatric nurse often has the initial therapeutic relationship with the family of children with neurogenic
disorders. This may be in the hospital, the pediatrician's office, or through home-health services. Because
of the trust that develops through this relationship, the information given by the professional nurse is
attended to and valued by the family. Through their recommendations then, nurses have a unique
opportunity to influence the development of the child's feeding behaviors. These recommendations should
be an outgrowth of thorough understanding of the deficits that interfere with successful feeding and
realistic modifications that can help remediate them. Knowledge regarding posture and its influence on
the feeding/swallowing process will enable the nurse to provide recommendations that enhance the
safety of feeding and may help the child progress to more developmentally mature stages of oral control.

Posture and Normal Feeding

Alignment of the oral structures for feeding is related to head and trunk stability (Bosma, 1972, 1986;
Langley & Thomas, 1991; Robbins, 1992). It is well documented that the child's head position influences
the swallow during feeding and reduces the risk of aspiration (Larnert & Ekberg, 1995; Logemann, 1998).
The recommended head posture for safe swallow is a "chin tuck." The head is upright, in midline, with
neck flexion, so that the chin is directed slightly downward and inward.

Head position is dependent on trunk control (Herman & Lange, 1999; Langley & Thomas, 1991; Seikel,
King, & Drumwright, 2000). To achieve this alignment of the head with the trunk, the pelvis must be
stabilized. This has important consequences for the entire process of swallowing. If the head is not stable,
then the fine movements of the jaw and tongue needed for feeding will be impaired (Jones-Owens, 1991;
Seikel et al., 2000). Thus, it appears that structures that are significantly distal to the oral area influence
its functioning (see Figure 1).

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 Figure 1. The Influence of Pelvic Stability on Oral Control for Feeding

The normal child may readily compensate for misalignment during feeding. However, for the child with
neurodisability any variation from the ideal head and trunk alignment may result in oral processing
difficulties that will compromise eating and swallowing.

Feeding Issues of the Child with a Neurodisability

Many of the children with neurodisabilities are those who are, or who will be, diagnosed with cerebral
palsy (CP). They may have been premature infants. They present with abnormal muscle tone and
reflexes that compromise feeding. The resulting oral sensorimotor deficits interfere with the oral
processing of food. In fact, the prevalence of feeding disorders in various samples of children with CP
have been reported to be as high as 80% (Rogers, Arvedson, Buck, Smart, & Msall, 1994), with
aspiration occurring in about 25% of these children (Arvedson & Brodsky, 2002). Frequent aspiration, of
course, is but a symptom of underlying pathophysiology. Oral-motor and lingual incoordination (Arvedson
& Brodsky, 2002; Daniels, Brailey, & Foundas, 1999); poor coordination between breathing and
swallowing (Couriel, Bisset, Miller, Thomas, & Clarke, 1993); and poor alignment of head, neck, and trunk
(Arvedson & Brodsky, 2002; Larnert & Ekberg, 1995) may be underlying causes of aspiration in children
with cerebral palsy.

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Successful processing of food relies on coordinated movements of the tongue, lips, and jaw, which
depend on the gross motor foundation of head and trunk control (Jones-Owens, 1991; Mueller, 2001;
Morris & Klein, 2000; Pinder & Faherty, 1999; Seikel et al., 2000; Stevenson & Allaire, 1996). Children
with CP lack this foundation and, thus, are unable to move their head independently. This is one of the
reasons that their oral movements for feeding are impaired (Bosma, 1992, 1997; Larnert & Ekberg; 1995;
Stevenson & Allaire, 1996).

Additionally, children with CP often exhibit hyperextension of the head and neck due to increased muscle
tone. Such hyperextension may also lead to tongue retraction (Larnert & Ekberg, 1995), jaw depression
(Bosma, 1992; Langley & Thomas, 1991), airway interference (Couriel et al., 1993), and a predisposition
to aspiration (Carroll & Reilly, 1996; Ekberg, 1986). Aspiration may be more likely because an extended
head position affects the relationship between the physical structures of respiration and gravity. This then
affects the coordination needed for swallowing and breathing (Seikel et al., 2000) (see Figure 2).
Therefore, one of the nurse's first goals of patient care should be the alignment of the head to an ideal
position for safe swallowing.

Figure 2. Causes of Feeding Disturbances in Children with Cerebral Palsy

Positioning

Safety and efficiency are enhanced with upright positioning and the use of a chin tuck head posture,
which allows food moving from the mouth through the pharynx into the esophagus to be directed away
from the airway. This position also provides greater stability of the mandible for improved suck/swallow in
the infant. However, maintaining this head posture is problematic in children with neurodisabilities. A
more holistic approach that stabilizes the body and aligns the head and trunk will make it easier for the
youngster with CP to maintain a chin tuck and will lead to better oral processing of food.

The typical position for bottle-feeding an infant is on the lap. The feeder should help maintain the infant in
an upright position with head/trunk alignment with his/her arm and/or body. Additionally, if one of the
feeder's legs is raised by placing his/her foot on a small footstool or box, the infant's hip flexion angle will
be decreased and hyperextension can be inhibited (see Figure 3).

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 Figure 3. Positioning an infant on an adult's lap using the adult's thigh as a wedge to inhibit extension.
The adult's foot is placed on a stool or foot support, raising one leg.

When developmentally appropriate, usually at about 6-8 months of age, the child should be seated in a
seat or high chair. Ideal sitting posture for eating requires the hips, knees, and feet to be at 90 degrees
with weight evenly distributed (Hall, 2001; Johnson & Scott, 1993). Again, the head should be at midline
with the chin pointed downward slightly. Positioning in a chair allows eye contact with the feeder,
facilitates communication, and in general makes feeding time more pleasurable. For those children with
extensor patterns that include pushing back with increased muscle tone, the hip-flexion angle can be
decreased by placing a wedge-cushion that is wider in the front under the child's knees.

The child's body should be positioned so that symmetry is achieved. Stabilizing the pelvis is fundamental
to this posture (Reid, Rigby, & Ryan, 1999), and providing foot support adds to the stabilization. If stability
is achieved at the pelvis, then improved control in the rest of the body will be reflected in better
functioning (Colbert, Doyle, & Webb, 1986; Herman & Lange, 1999; Hulme, Shaver, Acher, Mullette, &
Eggert, 1987; Reid et al., 1999). Although adaptive seating has been described as a "tool" to achieve
proper alignment, normal muscle tone (Herman & Lange, 1999), and pelvic stability (Colbert et al., 1986),
infants and young children grow so quickly that ordering expensive adaptive seating is usually not a
practical option. Often, towels, cushions, and wedges can be used to help maintain symmetry and head
flexion, while seat belts may be employed to stabilize the pelvis. The seat belt needs to be tight and well
placed, anchored below the seat and should extend over the pelvic region. The belt must never interfere
with breathing or go across the abdomen.

A tray on a high chair or any solid surface will help the youngster maintain alignment and trunk stability.
Some children will require a higher table to provide greater stability. Additionally, this will allow weight-

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bearing with elbows in front of shoulders, which facilitates shoulder girdle stability (Scott & Staios, 1993).
Again, providing stability enhances head/trunk alignment, facilitates the chin tuck, and improves oral
processing for feeding (see Table 1).

It is striking how often the child's oral stability improves once head and trunk alignment have been
attained. However, if the child cannot maintain a chin tuck position (with mouth closure) throughout a
meal, the clinician must then provide it more directly with oral control techniques.

Oral Control

Oral control can aid mouth closure; inhibit oral reflexes; and facilitate jaw, tongue, and lip movements for
feeding (see Table 2) (Arvedson & Brodsky, 2002; Hall, 2001; Mueller, 2001), while limiting abnormal
movements such as jaw protraction and extension. The starting position for feeding is mouth closure with
the tongue within the oral area. The feeder can then help the child make fine, graded movements of the
oral structures for feeding.

Oral control can be provided from the front (see Figure 4). In this case, the thumb is placed on the chin
influencing jaw movements, while the middle finger is under the chin influencing tongue position. Front
oral control permits eye contact between the child and the feeder but offers less oral control. It can be
used with infants in infant seats or with children attaining fair head control who need a sensorimotor
reminder to maintain head or jaw alignment. In general, infants require less oral control than older
children. A premature infant's suck is often characterized by disorganization, but abnormal tone may not
be apparent. These infants often need just one finger placed to give the mandible (jaw) enough stability to
allow the other oral structures to move more efficiently.

Figure 4. Front oral control allows for more interaction between the child and the feeder.

However, to provide oral control for the child with more profound oral-motor difficulties, oral control given
from the side allows the feeder greater influence over the movements of the oral structures. In this case,
the right-handed feeder uses the index and middle fingers of the non-dominant hand (i.e., left) while
standing or sitting on the right side of the child. The dominant hand is employed for feeding. The
nondominant arm must go around the back of the youngster's head, and the index finger of this hand is

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then placed midway between the lower lip and the bottom of the chin. The middle finger is placed under
the chin. These two fingers (that is, the middle finger and the index finger) work in tandem to maintain
proper tongue and jaw positioning (see Figure 5). It is important to note that if the middle finger exerts too
much pressure, the child may be pushed into an extended head position. This can be avoided if the little
finger is placed on the sternum while the middle finger is still under the chin, thus assuring the
maintenance of head position. However, it is also imperative that too much control not be exerted.
Otherwise, the child cannot move his/her head, and enjoyment of the eating experience will be diminished
(see Table 3).

Figure 5. Oral control from the side provides greater control over oral movements.

Conclusions

When infants and children with CP and other neurodisabilities have early feeding difficulties, it is the goal
of all disciplines working with the families to increase the child's skill development and provide the safe
intake of food. The most basic, essential, and effective treatment for children with neurogenic disorders
who have feeding/swallowing problems is positioning of the head/trunk and the oral area. Positioning
begins by facilitating trunk and head alignment. Then, oral control may influence the stability and
movement of the oral structures needed for feeding.

CE Information

The print version of this article was originally certified for CE credit. For accreditation details, contact the
publisher, Janetti Publications, Inc., East Holly Avenue Box 56, Pitman, NJ 08071-0056.

Table 1. Checklist for Proper Positioning of the Child with Neurodisabilities for
Feeding/swallowing

 Is the child upright? : Chair seat and back should be at 90 degrees and child maintained upright.
 Is he/she symmetrical? : Are hips, knees, and feet in 90 degree flexion?
 Are the feet stable? : Feet should be touching the floor. If not, foot support should be provided.

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  Is the pelvis stable?
 Is a well-positioned, tight seat-belt being used?
 Has a solid table surface been provided?
 Is the head in a chin tuck position? : If not, check the above items. : If a chin tuck position cannot
be attained through postural alignment, then oral control should be administered.

Table 2. Goals of Oral Control

 Attain and maintain closure of jaw and lips

Table 3. Checklist for Oral Control

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Fran Redstone, PhD, CCC-SLP, is Assistant Professor, Department of Speech-Language-Hearing

Joyce F.West, PhD, CCC-SLP, is Associate Professor, Department of Speech-Language-Hearing

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