Interventions for Feeding and Nutrition in Cerebral Palsy - Comparative Effectiveness Review Number 94 (Paperback)

Cerebral palsy (CP) is a "group of disorders of the development of movement and posture, causing activity limitation, that is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behaviour, and/or by a seizure disorder." This group of syndromes ranges in severity and is the result of a variety of etiologies occurring in the prenatal, perinatal, or postnatal period. Though the disorder is nonprogressive, the clinical manifestations may change over time as the brain develops, with other neurologic impairments frequently co-occurring. CP includes a spectrum of disorders of movement, posture, and coordination with heterogeneous etiologies. The diversity of the clinical features is reflected in multiple classification systems that include reference to type of motor dysfunction, body parts affected, severity, and functional abilities. Further classification is by severity level (mild, moderate, severe), and gross motor function, which reflects the functional capabilities of the affected. Developed in the late 1990s, the Gross Motor Function Classification System (GMFCS) outlines a standardized system for classifying motor function based on constructs of disability and functional limitation. The GMFCS includes levels that reflect abilities ranging from walking without limitations (level I) to severe head and trunk control limitations requiring extensive use of assisted technology, physical assistance, and a wheelchair (level V). We have synthesized evidence in the published literature to address these Key Questions: KQ1a. When compared with other nonsurgical interventions or no intervention, how effective are behavioral interventions, including positioning, oral appliances, oral stimulation, sensorimotor facilitation, and caregiver training, for improving nutritional state/growth, health outcomes, health care/resource utilization, and quality of life in individuals with CP and feeding difficulties? KQ1b. Is the effectiveness of behavioral interventions modified by age, race, severity, functional status (e.g., GMFCS level), or initial nutritional status? KQ2a. When compared with other nonsurgical interventions (e.g., positioning, oral appliances or stimulation) or no intervention, how effective are nutritional interventions (food thickeners, caloric supplementation with formulas, vitamin supplementation, and altering food consistency e.g., pureeing]) for improving nutritional state/growth, health outcomes, health care/resource utilization, and quality of life in individuals with CP and feeding difficulties? KQ2b. Is the effectiveness of nutritional interventions modified by age, race, severity, functional status (e.g., GMFCS level), or initial nutritional status? KQ3a. What is the comparative effectiveness of tube feeding when compared with oral feeding or with nutritional and behavioral interventions in individuals with CP who present with feeding difficulties, including malnourishment, failure to thrive, aspiration, and excessive caregiver burden? KQ3b. Among individuals with CP and feeding difficulties with significant reflux, what is the effectiveness of g-tube placement with fundoplication versus oral feeding for reducing reflux and for improving nutritional state/growth, health outcomes, health care/resource utilization, and quality of life? KQ3c. Among individuals who develop reflux after gastrostomy, what is the comparative effectiveness of j-tube versus fundoplication for reducing reflux in the short term and achieving improvements in nutritional state/growth, health outcomes, health care/resource utilization, and quality of life? KQ3d. Is the effectiveness of tube feeding modified by tube placement, age, race, severity, functional status (e.g., GMFCS level), initial nutritional status, or continuous versus bolus feeding?