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espite having a normal diet, considerable variation exists in the chewing ability of children with physical disabilities. These children may have an adequate or good pharyngeal swallow, but nevertheless have oral preparatory difficulties which make mealtimes slow and stressful for them and their families. In order to establish a better understanding of chewing ability in children with motor disabilities we have developed and tested an innovative, simple and reliable clinical research tool utilising chewing gum. The chewing gum is composed of two different colours which are mixed in the process of chewing. Chewing ability is characterised by an analysis of: (i) how well the two different colours were mixed together, indicating ability to manipulate a bolus and mix saliva into a bolus, and (ii) how well the bolus was shaped ready to be swallowed. Assessments, including evaluations of the consistency of the gum, carried out by speech and language therapists who were blinded as to the participants, has shown the procedure to have excellent reliability. This work involved typically developing children and children with a clinical description of cerebral palsy aged between 5 and 16 years. All children ate a normal consistency diet. Perhaps unsurprisingly, differences were observed in both the ability to manipulate the bolus, and in the ability to prepare it for swallowing between these two groups, with typically developing children performing better in both cases. Chewing ability was not related to severity of cerebral palsy nor was it related to sub-groupings of cerebral palsy (that is, athetoid, spastic and so forth). For example, a child with relatively severe cerebral palsy performed equally well in chewing ability as someone with mild cerebral palsy and vice versa. Both groups improved in their performance across all parameters with increasing age, but the differences between the groups remained. We were working with two groups of children who eat a normal consistency diet; the group with cerebral palsy do not therefore have the most severe oromotor difficulties. However, the differences in their oromotor abilities, reflecting the skills required for oral preparation of a food bolus, are significant. This suggests that not only are we seeing hidden variability in this population, but also that this tool is sensitive to small differences in ability. We would anticipate that the differences this tool reveals will have implications for quality of life, stress and family wellbeing within this group of children with cerebral palsy. We may extend the use of the gum to look at oro-motor skills more generally. We aim to develop the gum for clinical assessment and for the gum to be used as an objective baseline measurement which could be repeated as required and provide a functional outcome to enhance our evidence based practice. This work suggests that a proportion of children that present with relatively mild cerebral palsy and have a normal diet still experience significant difficulties with chewing and preparing food for swallowing. This is likely to have implications beyond their nutrital intake, for example, their attitude towards mealtimes, and stress around mealtimes. Clinicians should be wary of assuming that a normal diet represents a non-problematic situation.
Further reading Davis, E., Shelly, A., Waters, E., Boyd, R., Cook, K. & Davern, M. (2009) The impact of caring for a child with cerebral palsy: quality of life for mothers and fathers, Child: Care, Health and Development 36, pp.6373. Edwards, P. (2002) Bolus preparation in children with cerebral palsy using chewing gum: a comparison with normal children. MSc Thesis, UCL, London. Liedberg, B. & wall, B. (1995) Oral bolus kneading and shaping measured with chewing gum, Dysphagia 10, pp.101-106.
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