The Importance of Postural Control

for Feeding
Continuing Fran Redstone
Education Joyce E West
Series

Feeding Issues of the Child with

Children with cerebral palsy and other neurodisabilities often have a Meurodisability
decreased postural control that exacerbates their feeding/swallowing Many of the children with neurodis-
disorders. Correct postural alignment is important in the normal abilities are those who are, or who will
feeding/swallowing process. In the child with cerebral palsy, the be, diagnosed with cerebral palsy
alignment and stability of the oral structures for feeding/swallowing (CP). They may have been premature
may be compromised by abnormal muscle tone and movement pat- infants. They present with abnormal
muscle tone and reflexes that compro-
terns. Effective oral functioning for feeding begins with attaining bet- mise feeding. The resulting oral senso-
ter head stability to improve jaw control. Head control is influenced rimotor deficits interfere with the oral
by trunk alignment, which depends upon the stability of the pelvic processing of food. In fact, the preva-
area. Techniques such as therapeutic seating and oral control can lence of feeding disorders in various
enhance postural alignment and improve oral functioning for the safe samples of children with CP have been
intake of food. reported to be as high as 80% (Rogers.
Arvedson. Buck, Smart, & Msall.
1994), with aspiration occurring in
developmentally mature stages of oral

T
he pediatric nurse often has about 25% of these children (Arvedson
the initial therapeutic reia- control. & Brodsky, 2002). Frequent aspiration,
tionship with the family of of course, is but a symptom of underly-
children with neurogenlc dis-
Posture and Mormal Feeding ing pathophysiology. Oral-motor and
orders. This may be in the hospital, Alignment of the oral structures for lingual incoordination (Arvedson &
the pediatrician's office, or through feeding is related to head and trunk sta- Brodsky, 2002; Daniels. Brailey. &
home-health services. Because of the bility (Bosma, 1972, 1986; Langley & Foundas, 1999); poor coordination
trust that develops through this rela- Thomas. 1991; Robbins, 1992). It is between breathing and swallowing
tionship, the information given by the well documented that the child's head (Couriei. Bisset, Miller, Thomas, &
professional nurse is attended to and position influences the swallow during Clarke, 1993); and poor alignment of
valued by the family. Through their feeding and reduces the risk of aspira- head, neck, and trunk (Arvedson &
recommendations then, nurses have tion {Larnert & Ekberg, 1995;
a unique opportunity to influence the Logemann. 1998). The recommended
development of the child's feeding head posture for safe swallow is a "chin Figure 1. The Influence of Pelvic
behaviors. These recommendations tuck." The head is upright, in midline, Stability on Oral Control for Feeding
should be an outgrowth of thorough with neck flexion, so that the chin is
understanding of the deficits that directed slightly downward and inward.
interfere with successful feeding and Head position is dependent on Pelvic
realistic modifications that can help trunk control (Herman & Lange, 1999; Stability
remediate them. Knowledge regard- Langley & Thomas, 1991; Seikel.
ing posture and its influence on the King, & Drumwright. 2000). To
feeding/swallowing process will enable achieve this alignment of the head with
the nurse to provide recommendations the trunk, the pelvis must be stabilized. Trunk
that enhance the safety of feeding and This has important consequences for Control
may help the child progress to more the entire process of swallowing. If the
head is not stable, then the fine move-
ments of the jaw and tongue needed
for feeding will be impaired (Jones- Head
Fran Redstone. PhD, CCC-SLP, is
Assistant Professor. Department of Owens, 1991; Seikel et al., 2000). Control
Speech-Language-Hearing Sciences. Thus, it appears that structures that
Lehman College, Bronx, MY. are significantly distal to the oral area
influence its functioning (see Figure 1).
Joyce F. West, PhD, CCC-SLP, is The normal child may readily com- Jaw
Associate Professor, Department of pensate for misalignment during feed- Stability
Speech-Language-Hearing Sciences. ing. However, for the child with neu-
Lehman College. Bronx, MY. rodisability any variation from the ideal
>/ \
head and trunk alignment may result
The CE Posttest in oral processing difficulties that will Tongue Lip
can be found compromise eating and swallowing. Control Mobility
on pages 108-109.

PEDIATRIC NURSING/March-Aprii 2004/Vol. 30/No. 2

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

Gross motor pathologies Resulting in oral motor con- That may cause feeding dis-
may include: sequences such as: turbances:

Abnormal muscle tone Jaw instability Lack of food retention

Asymmetry of trunk/head Jaw depression Poor mastication of food
Hyperextension ot head Tongue retraction Delayed swallow
Misalignment of trunk/head Tongue incoordination Breathing/swallowing
Pelvic instability Lip retraction incoordination
Aspiration

Figure 3. Positioning an infant on an lead to tongue retraction (Larnert & weight evenly distributed (Hall, 2001;
adult's lap using the adult's thigh as Ekberg, 1995), jaw depression Johnson & Scott, 1993). Again, the
a wedge to inhibit extension. The (Bosma, 1992; Langley & Thomas, head should be at midline with the
adult's foot is placed on a stool or 1991). airway interference (Couriel et chin pointed downward slightly.
foot support, raising one leg. al., 1993), and a predisposition to Positioning in a chair allows eye con-
aspiration (Carroll & Reilly, 1996; tact with the feeder, facilitates com-
Ekberg, 1986). Aspiration may be munication, and in general makes
more likely because an extended head feeding time more pleasurable. For
position affects the relationship those children with extensor patterns
between the physical structures of res- that include pushing back with
piration and gravity. This then affects increased muscle tone, the hip-flexion
the coordination needed for swallow- angle can be decreased by placing a
ing and breathing (Seikel et al., 2000) wedge-cushion that is wider in the
front under the child's knees.
(see Figure 2). Therefore, one of the
nurse's first goals of patient care The child's body should be posi-
should be the alignment of the head to tioned so that symmetry is achieved.
an ideal position for safe swallowing. Stabilizing the pelvis is fundamental to
this posture (Reid, Rigby, & Ryan,
Positioning 1999), and providing foot support
Safety and efficiency are enhanced adds to the stabilization. If stability is
with upright positioning and the use of achieved at the pelvis, then improved
a chin tuck head posture, which control in the rest of the body will be
allows food moving from the mouth reflected in better functioning (Colbert,
through the pharynx into the esopha- Doyle, & Webb, 1986; Herman &
gus to be directed away from the air- Lange, 1999; Hulme. Shaver. Acher,
way. This position also provides Mullette, & Fggert, 1987; Reid et al.,
greater stability of the mandible for 1999). Although adaptive seating has
improved suck/swallow in the infant. been described as a "tool" to achieve
However, maintaining this head pos- proper alignment, normal muscle tone
ture is problematic in children with (Herman & Lange, 1999), and pelvic
Brodsky, 2002; Larnert & Ekberg,
neurodisabilities. A more holistic stability (Colbert et a l , 1986), infants
1995) may be underlying causes of
approach that stabilizes the body and and young children grow so quickly
aspiration in children with cerebral
aligns the head and trunk will make it that ordering expensive adaptive seat-
palsy.
easier for the youngster with CP to ing is usually not a practical option.
Successful processing of food Often, towels, cushions, and wedges
relies on coordinated movements of maintain a chin tuck and will lead to
better oral processing of food. can be used to help maintain symme-
the tongue, lips, and jaw, which try and head flexion, while seat belts
depend on the gross motor foundation The typical position for bottle-feed- may be employed to stabilize the
of head and trunk control (Jones- ing an infant is on the lap. The feeder pelvis. The seat belt needs to be tight
Owens, 1991; Mueller, 2001; Morris & should help maintain the infant in an and well placed, anchored below the
Klein, 2000; Pinder & Faherty, 1999; upright position with head/trunk align- seat and should extend over the pelvic
Seikel et al., 2000; Stevenson & ment with his/her arm and/or body. region. The belt must never interfere
Allaire, 1996). Children with CP lack Additionally, if one of the feeder's legs with breathing or go across the
this foundation and, thus, are unable is raised by placing his/her foot on a abdomen.
to move their head independently. small footstool or box, the infant's hip
This is one of the reasons that their flexion angle will be decreased and A tray on a high chair or any solid
oral movements for feeding are hyperextension can be inhibited (see surface will help the youngster main-
impaired (Bosma, 1992, 1997; Figure 3). tain alignment and trunk stability.
Larnert & Ekberg; 1995; Stevenson & Some children will require a higher
Allaire, 1996). When developmentally appropri-
ate, usually at about 6-8 months of table to provide greater stability.
Additionally, children with CP often age, the child should be seated in a Additionally, this will allow weight-
exhibit hyperextension of the head seat or high chair. Ideal sitting posture bearing with elbows in front of shoul-
and neck due to increased muscle for eating requires the hips, knees, ders, which facilitates shoulder girdle
tone. Such hyperextension may also and feet to be at 90 degrees with stability (Scott & Staios, 1993).

PEDIATRIC NURSING/March-April 2004/Vol. 30/No. 2

Table 1. Checklist for Proper Positioning of the Child with Table 2. Goals of Oral Control
IMeurodisabilities for Feeding/swallowing
>- Attain and maintain closure of jaw and lips
'J Is the child upright?
^ Chair seat and back should be at 90 degrees >• Grade jaw movements
and child maintained upright.
>- Inhibit jaw extension
• Is he/she symmetrical?
• Are hips, knees, and feet in 90 degree flexion? >• Inhibit jaw protraction
• Are the feet stable?
>• Feet should be touching the floor. If not, foot >- Influence tongue positioning
support should be provided.
>- Maintain chin tuck position
• Is the pelvis stable?
• Is a well-positioned, tight seat-belt being used?
ij Has a solid table surface been provided?
j Is the head in a chin tuck position?
If not, check the above items.
If a chin tuck position cannot be attained Again, providing stability enhances head/trunk alignment,
through postural alignment, then oral control facilitates the chin tuck, and improves oral processing for
should be administered. 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
Figure 4. Front oral control allows for more interaction then provide it more directly with oral control techniques.
between the child and the feeder.
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 pro-
traction and extension. The starting position for feeding is
mouth closure with the tongue within the oral area. The feed-
er 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 chil-
dren 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 pre-
mature infant's suck is often characterized by disorganiza-
tion, 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 5. Oral control from the side provides greater However, to provide oral control for the child with more
control over oral movements. 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 non-
dominant arm must go around the back of the youngster's
head, and the index finger of this hand is then placed mid-
way 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 tan-
dem 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 fin-
ger is placed on the sternum while the middle finger is still
under the chin, thus assuring the maintenance of head posi-
tion. However, it is also imperative that too much control not
be exerted. Otherwise, the child cannot move his/her head.

PEDIATRIC NURSING/March-Apri! 2004/VoI. 30/No. 2

 Table 3. Checklist for Oral Control mental approach. In M.B. Langley &
L.J. Lombardino (Eds.), Neuro-
Front Oral Control developmental strategies for manag-
ing communication disorders in chil-
Sit in front of the child or infant for eye contact dren with severe motor dysfunction
Use non-dominant hand fpp. 1-28). Austin, TX: Pro-Ed.
Thumb on chin Larnert, G., & Ekberg, O. (1995).
Positioning improves the oral and
Middle finger under chin
pharyngeal swallowing function in
children with cerebral palsy. Acta
Side Oral Control Pediatrica, 84. 689-692.
Logemann, J.A. (1998). Evaluation and
Right handed feeder sits on the left side of the child
treatment of swallowing disorders
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Index finger on chin Morris, S.E., & Klein, M.D. (2000). Pre-
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Mueller, H. {2001). Feeding. In N.R. Finnie,
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Don't exert too much pressure bral palsy at home {3rd ed.) (pp. 209-
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(1986). DESEMO seats for young chil-
When infants and children with CP dren with cerebral palsy. Archives of bilizer on children with cerebral palsy
and other neurodisabllities have early Physical Medicine and Rehabilitation, who use wheelchairs: Users' and
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