Consequences of Moderate to Severe TBI
The incidence of transient feeding and swallowing problems following traumatic brain injury is generally pervasive throughout the early stages of recovery. It is also not uncommon to find significant residual problems requiring long-term therapeutic intervention in this population. This section is intended to provide you with some basic information about assessment, treatment and appropriate diet advancements. Since this is an area that is often unfamiliar to the school speech-language pathologist, direct, ongoing communication with the hospital therapist for support and suggestions is recommended. This area also requires maximum input from the family.
Common Swallowing Problems
Common Swallowing Disorders
Risk of Receiving Suboptimal Nutrition
COMMON SWALLOWING PROBLEMS
Pocketing or pooling of food in the oral cavity
Poor tongue control or tongue thrusting
Coughing before or after swallowing
Excessive secretions, drooling or food lost from mouth
Wet-sounding or gurgly voice after eating or drinking
Pneumonia or elevated temperature
Regurgitation of material through nose, mouth or tracheotomy tube
Inadequate intake of food or fluid; weight loss
Excessive eating time
Mealtime resistance—clenching of teeth, pushing away of food, clutching throat, etc.
COMMON SWALLOWING DISORDERS
When assessing the swallow, we need to look at both the Oral Preparatory Phase and the Pharyngeal Phase.
Common Disorders in the Oral Phase
Primitive or pathological reflexes: rooting reflex, tonic or clonic bite reflex, food ejection
Abnormal muscle tone: Muscles in the lips, tongue, cheeks and jaw may be hypo- or hypertonic.
Abnormal sensation: Hypersensitivity may result in abnormal reflexes. Hyposensitivity may cause food to get lost out of the mouth, get lost in the mouth or prematurely fall into the pharynx.
Movement Disorders: A combination of abnormal reflexes, sensation and muscle tone can create characteristic movement disorders following a head injury.
Abnormal suckle-swallow or munch problems
Inadequate lip and cheek tension
A primary risk at this point is premature trickling or collection of food in the vallecular space, pyriform sinus or airway. This may place the child at risk for the aspiration of material into the lungs.
Common Disorders in the Pharyngeal Phase
Delayed or absent swallow reflex: aspiration before the swallow
Inadequate velopharyngeal peristalsis: nasal regurgitation
Uncoordinated pharyngeal peristalsis: nasal regurgitation
Poor coordination of airway protection valves: aspiration during swallow
Decreased tongue base pressure: aspiration after the swallow, secondary to residue in the vallecular space
Reduced laryngeal elevation:.aspiration after the swallow due to residue in the pyriform sinus
RISK OF RECEIVING SUBOPTIMAL NUTRITION
Some children have increased needs for energy because of the increased effort required for breathing or because of being especially physically active. At the same time, they may have decreased ability to take food because of effort required to eat or because a fluid limit is imposed. As a result, they often fail to grow, and their intake of vitamins, minerals and protein can also be compromised, leading to: poor immune function, inadequate energy to explore and learn and other problems.
Children with physical eating problems (chewing, swallowing, mouth control, etc.) may also receive inadequate intake because of the time and effort required to eat even a small volume of food and because of textural manipulations that can seriously limit the amount and variety of foods consumed. Careful analysis of the diet needs to be undertaken so that the nutritional needs are appropriate and adequate with foods that are easily/safely fed or eaten.
For some neurologically impaired children with unrecognized dysphagia the safety of oral feeding may not be considered, and aspiration pneumonias can result. Also, texture adjustments for dysphagia can themselves cause nutritional imbalance (e.g. a high starch:nutrient ratio as with use of food thickeners). Some neurologically impaired children will also experience changes in sensing hunger, thirst, or fullness. Their ability to taste and smell food may also be affected.
Some children have markedly decreased energy needs because of very low energy expenditure. They may need a very low caloric intake to prevent debilitating obesity. Intake of essential nutrients is inadequate on very low calorie diets unless the health professional looks closely at the feeding plan.
Children with lower body paralysis may also have serious problems with bladder infections and constipation, and a number of the traditional dietary interventions (such as corn syrup, cranberry or prune juice, etc.) contribute an unacceptably high number of calories for this group of children. Cranberries may decrease recurrence of bladder infection (as was shown in a study of elderly women) but an artificially sweetened product may be needed. Regular cranberry juice cocktail or prune juice provide about 2 calories per ounce; corn syrup provides 60 “empty” sugar calories per tablespoon. Well-intentioned interventions to solve one problem can seriously exacerbate another.
There are many pediatric conditions that greatly alter nutrient requirements and metabolism. The healthcare professional must examine diet alterations carefully. As always adjustments of the child’s diet must not only correct the problem (such as glucose control in diabetes) but it is also essential to examine the feeding plan to be sure it provides adequate and appropriate levels of all of the other nutrients.
Increased nutrient excretion or turn-over, or decreased absorption will alter nutrient requirements so that the “normal” guidelines of adequacy or safety (such as the “RDA” level) may not apply. They may not apply for other reasons as well, such as altered body composition or the effects of medications. Many guidelines only address intake goals for “healthy” people.
Many children are maintained on medications with important nutritional implications.
Chronic use of seizure medications (Phenobarbital, valproate (Depekene), phenytoin (Dilantin), and Tegretol) can cause increased turn-over of Vitamin D, osteoporosis and fractures. This is a special concern in northern latitudes where vitamin D status may be compromised, and among those who drink little milk (or use unfortified milk) and do not take a vitamin supplement. Other nutrients are also affected by these medications. Health professionals need to consider the influence of the medications when assessing the adequacy of nutrient intake.
Phenytoin(Dilantin) also interacts in a complex way with folic acid and several other vitamins, and its absorption is altered by the presence of food. When folate is found to be adequate and supplements are given to people on this medication, breakthrough seizures can occur. This does not happen when their folate level is never allowed to be depleted in the first place. Chronic users of these medications often have low erythrocyte folate levels. Inadequate folic acid is also associated with depression, poor response to antidepressants and risk of heart disease, stroke, colon cancer and Alzheimer’s disease. In pregnancy, the relatively poor folate status increases risk of significant birth defects.
Valproic Acid (Depakene) specifically interacts with carnitine and can cause metabolic disturbances including severe hypoglycemia and lethargy that impairs the child’s ability to function. It inhibits production of carnitine in the body, increasing dependence on external sources, and valproic acid also seems to require some carnitine for optimal drug effectiveness. Inadequate carnitine increases the amount of drug required for seizure control and it is associated with a much greater risk of serious liver toxicity from the drug.
Hydrocortisone (an anti-inflammatory) can cause growth failure, increase excretion of nitrogen and zinc, and decrease absorption of calcium and phosphate.
Antibiotics, when used chronically, can compromise the status of biotin, vitamin K (with bleeding problems and bone problems), and significantly impair folic acid absorption. Antibiotics can also induce a chronic diarrhea (and this may in turn be treated inappropriately with a clear liquid diet or half-strength feedings, resulting in further malnutrition.) Many people are commonly maintained on chronic antibiotics, including those with spinal cord injuries to prevent bladder infections.
Drugs also affect intake by causing nausea, vomiting, constipation, taste changes, lethargy or altered appetite. E.g., Methylphenidate (Ritalin), for attention deficit disorders may impair appetite enough to slow growth, although there is some evidence now that this may be less of a problem than originally thought.