Oral motor performance in spastic cerebral palsy individuals: are hydration and nutritional status associated?

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<ul><li><p>Oral motor performance in spastic cerebral palsyindividuals: are hydration and nutritional status associated?</p><p>Maria Teresa Santos1, Renato Batista1, Elisangela Previtali1, Adriana Ortega1, Oliver Nascimento2,Jose Jardim2</p><p>1Universidade Cruzeiro do Sul, Persons with Disabilities Division; 2Universidade Federal de Sao Paulo, Respiratory Diseases</p><p>BACKGROUND: Previous studies reported alterations in</p><p>salivary parameters in cerebral palsy (CP) individuals;</p><p>however, none of these considered oral motor perfor-</p><p>mance as possibly responsible for these conditions. The</p><p>aim of this study was to investigate the influence of oral</p><p>motor performance on the nutritional status and salivary</p><p>parameters in individuals with CP.</p><p>METHODS: Forty-three individuals aged 1119 years-</p><p>old, with spastic CP were included in this study. Oral</p><p>motor performance was evaluated using the Oral</p><p>Motor Assessment Scale, which classified the individuals</p><p>into two groups: subfunctional or functional. Unstimu-</p><p>lated saliva was collected and the flow rate was</p><p>calculated (ml min). Salivary osmolality was measuredusing a freezing point depression osmometer. Blood</p><p>samples were collected to evaluate complete blood</p><p>count, total protein, albumin globulin ratio and trans-ferrin levels.</p><p>RESULTS: The subfunctional (n = 21) and the functional</p><p>group (n = 22) did not differ regarding sex (P = 0.193),</p><p>however the functional group was older (P = 0.023) and</p><p>had a higher mean BMI (P &lt; 0.001). The subfunctional CP</p><p>group presented a reduction in salivary flow rate (36.4%)</p><p>(P &lt; 0.01) and an increase in salivary osmolality (35.5%)</p><p>(P &lt; 0.001) compared to the functional group. Slightly</p><p>lower values for red blood cells (millions mm3)(P &lt; 0.001), hemoglobin (g dl) (P &lt; 0.009), hematocrit (%)(P = 0.001), number of platelets (N mm3), total protein(g dl) and albumin globulin ratio (P = 0.003 and P = 0.036,respectively) were determined for the subfunctional</p><p>group, but within the normal range of normality.</p><p>CONCLUSION: Cerebral palsy individuals appear to</p><p>present impaired adequate hydration due to compro-</p><p>mised oral motor performance.</p><p>J Oral Pathol Med (2012) 41: 153157</p><p>Keywords: cerebral palsy; saliva; salivary parameters; osmolality;</p><p>hydration; oral motor performance; nutritional status</p><p>Introduction</p><p>Individuals with functional neurological damage, par-ticularly those with cerebral palsy (CP), often presentseveral disorders that are accompanied by disharmonicmovements, including oral motor performance ofspeech, mastication and swallowing (1).The limited motor performance of mastication and</p><p>swallowing in children with CP, a neurodevelopmentaldisability (2), results in feeding dysfunctions thatinclude several interacting variables, including dys-functional oral motor control (weak sucking, persis-tent tongue thrusting and poor lip closure), abnormalneurological maturation (presence of oral pathologicalreexes), and poor seating posture during feeding.These abnormalities may result in reduced dietaryintake, prolonged feeding times and poor nutri-tional status with their attendant physical compromise(37).It has been reported that children with CP can present</p><p>low salivary ow rate, pH and buer capacity (8).Increased salivary osmolality and total protein concen-tration (9), as well as increased salivary, urine andplasma osmolalities were also veried in these individ-uals, characterizing impaired adequate hydration status(10). These ndings lead us to believe that the dailyamount of liquid intake is usually reduced in theseindividuals. These conditions could be due either to alow amount of liquid oered to these individuals, or tocompromised oral motor performance that may hamperthe liquid diet intake. If it were the case that thehypohydration status was due to the insucient oer bytheir caregivers, then subnutritional status should alsobe observed.Considering the points raised above, the aim of this</p><p>study was to investigate the inuence of oral motorperformance on the nutritional status and salivaryparameters in individuals with spastic cerebral palsy. It</p><p>Correspondence: Maria Teresa B. Santos DDS, PhDAssociate Professor, Individuals with Special Needs, UniversidadeCruzeiro do Sul, Rua Constantino de Souza, 454, apto 141 Zip code:04605-001 Sao Paulo, Brazil. Tel: +551199722301, Fax: +551150930865, E-mail:drsantosmt@yahoo.com.brAccepted for publication August 4, 2011</p><p>doi: 10.1111/j.1600-0714.2011.01074.x</p><p>J Oral Pathol Med (2012) 41: 153157</p><p> 2011 John Wiley &amp; Sons A/S All rights reserved</p><p>wileyonlinelibrary.com/journal/jop</p></li><li><p>was hypothesized that compromised oral motorperformance interferes in liquid and solid dietintake, resulting in diminished health status for theseindividuals.</p><p>MethodsSubjectsThis project was approved by the Cruzeiro do SuIUniversity Institutional Review Board (IRB) underprotocol number 045 2010. After being informed ofthe aim of the investigation, written informed consentfor participation and publication was obtained from theadult responsible for each individual.Forty-three male and female individuals, aged</p><p>1119 years old, diagnosed with spastic cerebral palsy,who attended the Fraternidade Irma Clara Institution,in Sao Paulo, Brazil, were included in this study. Theinclusion criteria were: individuals with a clinical med-ical diagnosis of spastic cerebral palsy; and the exclusioncriteria were use of any drug that could interfere withsaliva secretion (anticholinergic and neuroleptic drugs,benzodiazepines) for at least 72 h prior to examination,a history of head and neck radiation and surgicalprocedures to reduce drooling.The patients medical records were reviewed for</p><p>demographic and clinical data and body mass index(BMI).</p><p>Oral motor performancePatient oral motor performance was evaluated duringthe feeding process using the Oral Motor AssessmentScale (11). The following topics were evaluated: mouthclosure, lip closure onto the utensils, lip closure duringdeglutition, control of food during swallowing(solid semisolid), mastication, straw suction and controlof liquids during deglutition.A score was given for each topic of the oral motor</p><p>skill assessed. A nal classication of the oral motorskill was obtained based on the most frequent score.The individuals were classied as: passive (severelycompromised oral motor performance), subfunctional(moderately compromised oral motor performance),semi-functional (slightly compromised oral motor per-formance) and functional (very slightly compromisedoral motor performance) (11).</p><p>Saliva collectionUnstimulated whole saliva was collected using slightsuction through a soft plastic catheter. The salivaproduced in the rst 10 s was discarded and allsubsequent saliva was collected for exactly 5 min in agraduated cylinder in order to calculate the ow rate(ml min). During the collection period, all the childrenremained comfortably seated in a ventilated and illumi-nated room. When it was not possible to collect salivafrom a child due to crying, they were excluded. Soonafter collection, the saliva sample was frozen in dry ice,transported to the laboratory and stored at )80C untilanalysis. Salivary osmolality was measured using afreezing point depression osmometer (Model Wide-</p><p>Range Osmometer 3W2; Advanced Instruments, Need-ham, MA, USA).</p><p>Body mass index calculationSince individuals with CP present diculties instanding straight, height was measured by the tibiasegment length in centimeters and the estimatedstature was determined from segmental measures usingthe equation: Stature = (3.26 x tibia segment) +30.8 cm (12). For individuals seated in a wheelchair,weight was measured with the patient sitting in theirwheelchair in a digital balance, and later the weightof the chair was subtracted from the total. Finally,body mass index was calculated as weight stature2(kg m2).</p><p>Blood collectionBlood samples were collected to evaluate completeblood count, total protein, albumin globulin ratio andtransferrin levels using venostasis from an antecubitalvein into separate Vacuteiner tubes containing ethylen-ediaminetetraacetic acid (EDTA) (Becton Dickson, Juizde Fora, Brazil).</p><p>Statistical analysisTo evaluate proportional dierences between the groupsstudied, the chi-square test was used. The Studentst-test was used to verify the hypothesis of equalitybetween the two groups. Spearmans correlation coe-cient was used to associate the behavior of fourvariables. The signicance level was set at P &lt; 0.05.</p><p>Results</p><p>Individuals determined as having a nal predominancetype of passive and subfunctional (severely and moder-ately compromised oral motor performance) were clas-sied into a single group that was denominated thesubfunctional group (n = 21), while the semi-functionaland functional individuals (slightly and very slightlycompromised oral motor performance) were denomi-nated the functional group (n = 22).The individuals from both groups did not dier</p><p>regarding sex (P = 0.193), but the functional group was</p><p>Table 1 Descriptive characteristics of individuals with cerebral palsywith subfunctional and functional oral motor performance groups</p><p>Individual variables</p><p>Subfunctionalcerebral palsy(n = 21)</p><p>Functionalcerebral palsy(n = 22) P value*</p><p>Sex, n (%) 0.193a</p><p>Female 15 (71.4) 17 (77.3)Male 6 (28.6)) 5 (22.7)Age, mean [SD] years 14.2 2.8 16.2 2.9 0.023*b</p><p>BMI (kg m2) 14.2 2.1 16.9 0.83 </p></li><li><p>signicantly older (P = 0.023) and had a signicantlyhigher BMI (P &lt; 0.001) (Table 1).Data of salivary ow rate (ml min) and salivary</p><p>osmolality (mOsm kgH2O) from the subfunctional andfunctional CP groups are presented in Table 2. Thesubfunctional CP group presented a 36.4% reduction insalivary ow rate (P &lt; 0.01) and an increase of 35.5%in salivary osmolality (P &lt; 0.001) compared to thefunctional group.The subfunctional group presented lower values for</p><p>red blood cells (millions mm3) (P &lt; 0.001), hemoglo-bin (g dl) (P &lt; 0.009), hematocrit (%) (P = 0.001)and number of platelets (N mm3) (Table 3). Addition-ally, this group presented signicantly lower values fortotal protein (g dl) and the albumin globulin ratio(P = 0.003 and P = 0.036, respectively) (Table 4).Table 5 shows the values of the Spearmans correla-</p><p>tion coecient for salivary ow rate, salivary osmolal-ity, BMI, total protein and albumin globulin ratio ofthe two groups studied. Salivary osmolality was nega-tively correlated with salivary ow rate (R = )0.82,P &lt; 0.01), BMI (R = )0.66, P &lt; 0.01), total protein(R = )0.54, P &lt; 0.01) and albumin globulin ratio(R = )0.52, P &lt; 0.01). Salivary ow rate correlatedpositively with BMI (R = 0.74, P &lt; 0.01) and totalprotein (R = 0.57, P &lt; 0.01).</p><p>Discussion</p><p>Understanding the impact of oral motor dysfunctionmay be helpful in identifying individuals at high risk ofdeveloping oral diseases. The results of this studysuggest that individuals with CP presenting greater oralmotor performance impairment also present reducedsalivary ow rate and increased salivary osmolality,which is indicative of hypohydration status compared tothose with better oral motor performance. However, inboth groups, nutritional status was within the normalrange, according to the parameters evaluated. Analysisof these results does not support the hypothesis raised inthis study, since compromised oral motor performancein individuals with CP only interferes in liquid dietingestion, conrming the hypohydration status previ-ously reported (810).The tool used in this study to assess oral motor</p><p>performance is an accurate and valid method forevaluating feeding dysfunction in this population (11)and made possible to divide the individuals studied intotwo distinct groups.Even though CP results from a permanent static</p><p>lesion to the central motor cortex (2), the lesion itselfdoes not change, but the clinical manifestations of thelesion may change as the child grows up (13). Althoughthe functional and subfunctional oral motor perfor-mance groups dier regarding age, it is important totake into account the fact that oral motricity is directlyrelated to the brain damage caused by CP, rather thanassociated with developmental changes that are modi-ed by hormones and puberty.</p><p>Table 2 Salivary ow rate (ml min) and salivary osmolality(mOsm kg H2O) of individuals with cerebral palsy with subfunctionaland functional oral motor performance groups</p><p>ParametersSubfunctionalcerebral palsy</p><p>Functionalcerebral palsy P value*</p><p>Salivary ow rate 0.32 0.15 0.88 0.21 </p></li><li><p>The severe oral motor dysfunction observed in CPindividuals with subfunctional oral motor performancein this study was responsible for the signicant reducedBMI observed, since the development of successfulfeeding skills requires the presence of normal anatomicalstructures involved in oral preparation, the swallowreex, and the natural progression of learned behaviorto achieve the complex process of feeding (14). Inaddition, this condition may cause limited food andwater intake, poor growth and may indicate a risk foroverall health (15).Salivary osmolality has been described as a reliable</p><p>parameter of hydration status and reects changes inplasma and urine osmolality in CP individuals (10).The higher salivary osmolality observed in the CPindividuals with subfunctional oral motor performanceis very similar to the osmolality presented by individ-uals submitted to conditions of dehydration (9), sug-gesting a reduced amount of liquid diet intake by thisgroup.The hemoglobin level has been widely accepted as an</p><p>important index of nutritional status (16). The CPindividuals with subfunctional oral performance in thisstudy showed a slight but signicant reduction inhemoglobin levels in comparison to the functionalgroup, although the hemoglobin of both groups werewithin the normal range of normality (13.9 0.52 formales and 13.4 0.76 for females). Few studies havediscussed this issue in CP individuals (16, 17). Norm-ocytic normochromic anemia was described in 19 casesof a sample composed by 90 institutionalized, adult,Japanese, CP individuals with a mean age of 42.1(10.7) years old. It should be highlighted that theindividuals evaluated in the study (16) were almostthree times the age of those evaluated in the presentstudy and that the cause of anemia could be due todiminished iron absorption, common in older individ-uals.No protein decit was observed in either of the CP</p><p>groups in this study, demonstrating that the proposednutritional monitoring (behavior therapy, follow-upmonitoring, anthropometric measurements and nutri-tional education) provided for the individuals with CPby the institution was sucient to maintain theirnutritional status, but not their hydration status.The issue of hydration status and liquid diet intake</p><p>in individuals with CP has rarely been described in theliterature (9, 10). Solid and semisolid food consistenciesprovide greater proprioceptive stimuli inside themouth, which facilitates the control of swallowing. Inindividuals with CP who cannot sustain lips closure,the liquid diet intake usually ows out of the mouth,resulting in the lack of negative pressure for swallow-ing, which may cause choking. In...</p></li></ul>