Historically, severe malnutrition has been accepted as unavoidable and irremediable consequence of neurological impairment . Poor nutritional state was often marked by linear growth failure, decreased lean body mass, and diminished fat stores [6, 7]. Over the past two to three decades, multidisciplinary feeding programs providing comprehensive evaluation and treatment of feeding disorders in children with developmental disabilities have been instrumental in improving the nutritional status, quality of life, and reduced hospitalization rates [8]. Studies on small number of children with developmental disabilities have demonstrated that adequate nutritional support, provided by less invasive enteral access methods and better tolerated enteral formulas, may improve weight, muscle mass, subcutaneous energy store, peripheral circulation, the healing of decubitus ulcers, and general well-being, while decreasing irritability and spasticity [9, 10].

The true prevalence of undernutrition in neurologically impaired children is unknown. It has been estimated that approximately one third of them are undernourished and many exhibit the consequences of malnutrition [7]. Yet, the incidence and severity of malnutrition increases with the duration and the severity of neurological impairment [11–13]. Parameters to assess malnutrition and overnutrition in the handicapped child have to be adjusted. Height is a proper parameter for growth and nutritional status, but difficult in children with malformations and spasticity [14–16]. Also, disproportionate development of the head, rump, and extremities makes assessment of height as a parameter of nutritional status difficult [17–19]. Therefore, crown–rump length, width, crown–heel length, distal femoral length, and distal arm length (Spender growth curve) have been developed to assess growth and to relate height to developmental abnormalities or to nutrition [20]. In a study on more than 2000 institutionalized children with a handicap in Tokyo, Japan, height and weight were measured in four distinct groups. Groups were divided into deaf children, blind children, mentally retarded children, some of whom were completely ambulatory, and 15 % of whom needed crutches, and physically handicapped children, of whom 65 % were nonambulatory. Height more than three standard deviations below the mean was present in 2 % of deaf children, 10 % of blind children, 15 % of children with mental retardation, and 45 % of physically handicapped children. Underweight more than two standard deviations below the mean was present in 1 % of deaf children, 4 % of blind children, 5 % of children with mental retardation, and 24 % of physically handicapped children [15]. In a Finnish study of patients up to the age of 20, the body mass index (BMI) showed that underweight (BMI < 20 kg/m²) was present in 30 %, overweight in 10 %, and severe overweight in 7 % (BMI > 32 kg/m²) [21].

The predominant nutritional deficit in neurologically impaired children is in energy intake, with only 20 % of these children regularly ingesting 100 % of their estimated average requirement. Moreover, half of the children with severe disabilities consumed less than 81 % of the reference nutrient intake for copper, iron, magnesium, and zinc, with that influenced by their large consumption of milk [22].

Nutritional support is essential for the care of neurologically impaired children. Undernourished handicapped children might not respond properly to intercurrent diseases and suffer unnecessarily. On the other hand, restoring a normal nutritional status results in a better quality of life in many. Assessment of nutritional status requires a proper follow-up of height, body weight, and assessment of the standard deviation score. By so doing, negative changes are easily discovered and appropriate nutritional intervention can be initiated. An individualized intervention plan that accounts for the child’s nutritional status, feeding ability, and medical condition should be determined. Energy requirements must be individualized considering mobility, muscle tone, activity level, altered metabolism, and growth. The easiest and least invasive method to increase energy intake is to improve oral intake. Food caloric density may be increased by adding modular nutrients, modifying recipes, or using high-calorie formulas. Children who cannot chew effectively may be able to receive the same foods blenderized into a puree of acceptable consistency. Those who can tolerate solids but not liquids can have commercial thickeners added to their fluids. Oral feeding skills may be improved with therapy, even if the results may be disappointing [23–25].Adequate positioning of the child during meals and appropriate food temperature are furthermore important. However, oral intake can be maintained as long as there is no risk of aspiration, the child is growing well, and the time required to feed the child remains within acceptable limits.

When oral intake is unsafe, insufficient, or too time consuming, enteral nutrition should be initiated. The type of enteral access will depend on the anticipated duration of enteral nutrition support as well as the clinical status of the child . Nasogastric tubes are minimally invasive but are easily dislodged and have local complications such as sinusitis, congestion, otitis, and skin irritation. Generally, nasogastric feeds should only be used for a short-term nutritional support (less than 3 months). For long-term enteral nutrition support, a gastrostomy should be considered. Gastrostomies are more invasive, but are also more convenient and esthetically acceptable. Gastrostomy placement has been shown to reduce feeding time, food-related choking episodes, frequency of chest infections, and family stress, and to improve weight and nutritional status significantly in children with severe neurologic impairment [10, 18].However, percutaneous endoscopic gastrostomy (PEG) is not without complications or concerns. Minor catheter infections, perforation, and an overall lessened length of survival have being described in both adult and pediatric populations [26–31].

The anatomy and function of the stomach should be carefully evaluated before the placement of the feeding tube. The coexistence of gastroesophageal reflux (GER) may require a simultaneous fundoplication, and delayed gastric emptying must necessitate pyloroplasty or duodenal placement of the distal portion of the tube. Physiologically designed formulas of increased caloric and protein density can be used for gastric and nasogastric infusion, as palatability is no longer an issue. The choice between bolus and drip may depend on esophagogastric function, the volume to be delivered, or the home care needs of the child and his or her caregivers. Often patients may benefit from a combination of daytime bolus and nocturnal continuous feeds, the latter providing 30–50 % of the child’s nutrient needs and thus allowing more freedom for daily activities. When safety of oral feeding is not an issue, these enteral techniques can merely supplement the child’s own nutrition, with caregivers continuing to feed the child actively. This dual feeding method often provides great satisfaction to parents and caregivers, because the mealtime interaction is improved when there is no longer a need for force-feeding of medication or nourishment.

Oral motor dysfunction is a frequent concomitant and often one of the first signs of neuromuscular impairment. Related swallowing problems have been shown to affect up to 90 % of neurologically impaired children, being major contributors to malnutrition [1]. This is not surprising since the development of oral–motor skills mirrors general neurological maturation and requires the coordination of the movement of several striated muscles in the mouth, pharynx, and esophagus by six cranial nerves, the brain stem, and the cerebral cortex. In addition, anatomic abnormalities such as cleft palate, laryngeal clefts, and tracheoesophageal fistula may accompany neurologic deficits as part of a congenital or genetic syndrome. Dysphagia may manifest as distress during meals (including coughing, choking, and refusal of feeding), chronic or episodic aspiration-related respiratory disorder, and failure to thrive. Barium swallow, cine swallow, radionuclide esophageal clearance scan, and esophageal manometry may all be of some help in the clinical assessment. Successful management of dysphagia is central to the child’s well-being and ability to achieve his or her potential. Neurologically impaired children often show greater problems with liquid foods, thus requiring the use of thickener products. Oral motor exercise approaches using sensory modalities may help improving muscle strength and oral coordination. Nevertheless, in most cases, the presence of unsafe swallows and/or long-lasting distressed meals finally lead to the choice of enteral nutrition.