A significant percentage of children with hypoxic-ischemic encephalopathy (HIE) may require specialized dietary plans due to a wide variety of reasons – some cannot chew or swallow properly (as with cerebral palsy), some are at risk of malnutrition due to physical difficulty eating, and others may sometimes have dysfunctional reflexes that can pose a choking hazard. Dysphagia occurs most commonly in individuals with central nervous system injury, which can include individuals with HIE, cerebral palsy, stroke, or traumatic head injury. For these children, it may be necessary to modify the calorie density of their meals, change the form in which they are provided, or change mealtime strategies to maximize eating efficiency. This should be done under the supervision of a physician, nutritional counselor and/or registered dietician, who can provide help and advice regarding numerous nutritional concerns. Here, we’ll discuss some of the issues that can impact nutritional health.
Dysphagia is an ‘oral-motor dysfunction’ that makes swallowing difficult. When a child has dysphagia, they are at increased risk of choking and/or aspirating their food. Because of this, monitoring during mealtimes may be needed. Generally, this occurs with children who have a moderate-to-severe case of cerebral palsy, where the muscles of the face and neck cannot execute the complex movement needed to move food and liquid from the child’s mouth to the stomach.
There are two different kinds of dysphagia:
- Oropharyngeal dysphagia: The result of abnormalities in the muscles and nerves of the oral cavity, pharynx and esophageal sphincter. This is most often related to nerve and muscle malfunctions that weaken the throat muscles, making it difficult to move food from mouth to throat.
- Esophageal dysphagia: A result of the muscle malformations or a malfunction of the lower esophageal sphincter. This type of dysphagia can issues with the movement of food down the esophagus to the stomach.
Dysphagia can manifest in different ways – while the most common sign is difficulties with eating, dysphagia can also cause problems with speaking, which uses the same muscles as eating and chewing. Often, the physical difficulty of eating can reduce the amount of food a child will be able to eat, as dysphagia can also make a child tire easily during eating.
The following chart outlines some signs of dysphagia:
|Dysphagia-related Issues directly related to feeding||Dysphagia-related issues related to speech||Other Potentially Dysphagia-related Health Concerns|
|Falling asleep during feeding||Ataxic dysarthria||Back or chest pain|
|Aspirating food||Difficulty controlling vocal cords (resulting in nasal speech)||Choking|
|Apnea during feeding (falling asleep during feeding)||Difficulty voicing or articulating speech||Constant cough|
|Delayed and/or absent swallowing reflex||Spastic dysarthria||Drooling|
|Difficulty and/or unwillingness to feed||Verbal apraxia||Dry mouth|
|Spasms in the esophagus||Fatigue|
|Sensation of throat obstruction||Heartburn|
|Pain while swallowing||Nasal regurgitation|
|Difficulty or inability to make mouth movements||Sluggishness, lack of energy|
|Taking a long time to eat||Sore throat|
|Resistance to feeding||Tongue thrust|
|Unexplained weight loss|
Because dysphagia often means that children with HIE eat smaller quantities of food, they are at risk of not receiving enough nutrients. Food intake should be closely monitored and parents should work with a nutritionist to ensure the child has adequate macronutrients, vitamins, minerals and other dietary components. Sometimes this might mean supplementation or consultation with a dietary specialist to help figure out the best way to ensure the child intakes enough. Malnutrition can increase the risk of a child failing to thrive, grow or develop according to expected values, and can exacerbate existing conditions.
If a person loses more fluid than they retain, brain swelling, low blood volume shock, kidney failure and other adverse events may occur. Low fluid intake (due to fear of choking, aspiration, or breathing issues) must be monitored and remedied.
Respiratory issues may stem from dysphagia-related aspiration. Aspiration of food or liquid into the lungs can cause pneumonia, a serious infection of the lungs.
Consulting with Specialists
Parents who are concerned about their child’s nutritional intake can consult with one of several specialists trained in helping to recognize, understand and mitigate nutrition-related health concerns. Often, this requires assessment and evaluation by multiple specialists, including clinical dieticians, occupational therapists, speech-language pathologists, pediatricians, radiologists, neurologists and otolaryngologists (ear/nose/throat doctors), each of which plays a different role in developing a comprehensive nutritional plan.
To learn more about the concrete steps that specialists and parents can take to mitigate the risks of malnutrition with HIE, visit our Care Considerations > Eating, Feeding and Meal Planning page.