The life expectancy of profoundly handicapped people with mental retardation

Total esophagogastric dissociation: 10 years' review

PURPOSE

Neurologically impaired children run a 12% to 45% risk of recurrent gastroesophageal reflux (GER) after fundoplication. Elimination of the reflux by "rescue" total esophagogastric dissociation (TEGD) encouraged us to use it also as a "primary" form of antireflux surgery in this group of patients.

METHODS

Twenty-six (14 male, 12 female) patients underwent TEGD between 1994 and 2004, of which 16 were primary and 10 were rescue procedures for failed fundoplication.

RESULTS

There was no operative mortality and postoperative complications were limited to one subphrenic collection, one esophagojejunal dehiscence, and one small bowel hernia beneath the jejunal Roux loop. Gastrostomy feeding was usually established by 3 to 5 days and the mean hospital stay was 10.2 days (range, 6-18 days). At follow-up of 7 months to 11 years, there was no recurrence of GER. Four late deaths were unrelated to the surgery. The children's nutritional status improved with the mean weight standard deviation score showing a statistically significant increase from -2.63 preoperatively to -0.96 postoperatively (Wilcoxon's signed rank P value < or =.005).

CONCLUSIONS

Total esophagogastric dissociation is a safe definitive solution for GER because it eliminates all risk of recurrent reflux. We therefore feel that TEGD can be used as a primary treatment of choice for severely neurologically impaired patients who are experiencing GER and are completely dependant on tube feeds.

Costs and complications of hospitalizations for children with cerebral palsy

BACKGROUND

Although many children with cerebral palsy (CP) develop secondary conditions requiring hospitalization, in-patient hospital utilization by this population has not been characterized.

OBJECTIVE

To characterize hospitalizations in children with CP and to compare them with hospitalizations of those without CP using a large national data set.

METHODS

Analysis of the Healthcare Utilization Project Kid Inpatient Database, a weighted survey of paediatric discharges from US hospitals in 1997.

RESULTS

In 1997, 37,000 children with CP were hospitalized, generating charges approaching 600 million dollars. Children with CP demonstrated longer lengths of stay (6.3 vs 4.1 days, p < 0.001), higher total charges (16,024 vs 9952 dollars, p < 0.001), more diagnoses (5.6 vs 3.0, p < 0.001) and more procedures (1.7 vs 1.1, p < 0.001) per admission. Five major diagnostic categories accounted for 83.2% of the discharge diagnoses for children with CP (48.6% for those without CP, p < 0.001). Children with CP were more often transferred to other facilities (p < 0.001) or prescribed home health care (p < 0.001) upon discharge.

CONCLUSIONS

Hospitalization of children with CP represents a major expenditure for health care systems. Studies to improve the management of conditions associated with CP could result in better outcomes for children and families and potentially decrease costs associated with hospitalization.

Kidney Transplantation in Pediatric Recipients With Mental Retardation: Clinical Results of a Multicenter Experience in Japan

BACKGROUND

There are few published reports on kidney transplantation (KT) in physically handicapped patients with mental retardation. The aim of this study is to clearly identify the outcome of KT in these patients and clarify whether handicapped patients can be candidates for KT.

METHODS

Our study identified 25 multiply handicapped transplant recipients from 8 institutions. Causes of mental retardation were chromosomal abnormality in 5 patients, genetic syndrome in 10 patients, developmental brain anomaly in 2 patients, and other or unknown causes in 8 patients. Primary diseases leading to end-stage renal disease were congenital urinary tract anomaly in 12 patients, focal segmental glomerulosclerosis in 3 patients, cystic kidney disease in 3 patients, and other in 7 patients.

RESULTS

Twenty-three patients received living-related transplants from a parent and 2 patients received cadaver transplants. Twenty-two patients were on peritoneal dialysis therapy, 2 patients were on hemodialysis therapy at the time of KT, and 1 patient underwent preemptive KT. Eleven acute rejection episodes occurred in 8 patients. All episodes were completely reversed with treatments that included mainly methylprednisolone pulse therapy. Posttransplantation lymphoproliferative disorder occurred in 2 patients. Follow-up data showed that all grafts were functioning during a mean observation period of 41.1 months (range, 4 to 187 months). All persons providing primary support for patients were satisfied with the KT and believed that quality of life was improved in both transplant recipients and themselves.

CONCLUSION

Results indicate that KT is not contraindicated in handicapped patients, but cannot determine which patients are unsuitable to undergo KT.

Life expectancy in severe cerebral palsy

Cerebral palsy comprises an important component of paediatric and obstetric practice and has major medico-legal implications. The prognosis for survival in cerebral palsy determines the financial provision made in cases that come to litigation. Issues of data quality and estimation methods are critical. Estimating the probability of survival in cerebral palsy based on clinical experience is liable to serious error unless numerical data can be produced. Only an actuarial analysis based on a standard life table of cases of cerebral palsy will enable a valid estimate of survival. Construction of the table requires a total cohort of cases of cerebral palsy with their date of birth. Each case must conform to a specified definition of the syndrome. Notification of all those who die, with their date of death is mandatory. Estimating the probability of survival according to the severity of functional disability requires specific definitional criteria for each severity category and for those categories to be mutually exclusive. Survival is significantly poorer in those with severe disability. Severe cognitive, motor (manual and ambulatory), and visual disabilities have independent effects on the probability of survival. Severe hearing disability does not add additional information when the other four functional disability categories are included.

Total oesophagogastric dissociation: experience in 2 centres

BACKGROUND/PURPOSE

Neurologically impaired (NI) children have an increased incidence of gastroesophageal reflux and many will require surgery.

METHODS

The case notes of 50 NI children who underwent total oesophagogastric dissociation (TOGD) were reviewed. Thirty-four were done as a primary procedure, and 16 were rescues for failed fundoplications.

RESULTS

There was no operative mortality. Morbidity consisted of 1 subphrenic collection, 1 oesophagojejunal dehiscence and 2 stenoses that responded to dilatation, and 2 bowel obstructions. In 1 case, partial gastric resection was needed because of transhiatal herniation of stomach. Gastrostomy feeding was established by 3 to 5 days. The mean hospital stay was 10.9 days. At 4 months to 11 years of follow-up, there was no recurrence of reflux. Children who could swallow enjoyed oral feeds. Their general health and weight SD scores improved. Food aspiration, chest infections, and hospitalizations were reduced, with an improvement in quality of life. There were 5 late deaths in the "primary" and 7 in the "rescue" group from deterioration in their original condition.

CONCLUSION

Total oesophagogastric dissociation is a safe and versatile procedure without immediate mortality and limited surgery-related morbidity. Review of our practice suggests TOGD should be considered as a primary procedure in severely NI children with gastroesophageal reflux and significant oropharyngeal incoordination and dependence on enteral tube feeding. Rescue TOGD carries a greater morbidity because of previous surgery with consequent difficult dissection, poor oesophageal tissue, and higher incidence of vagal nerve injury.

The effect of viscosity on the breath-swallow pattern of young people with cerebral palsy

In this observational pilot study, we investigated the effect of swallowing pudding and liquids of different viscosity on the breath-swallow pattern of young people with quadriparetic cerebral palsy (CP) and normal controls. A noninvasive acoustical technique was used to monitor breaths and swallows while the individuals were drinking thin and thick liquids and consuming pudding. The results showed that subjects with CP had a significantly higher rate of post-swallow inspiration than controls when they were drinking thin liquid but not when they were consuming thick liquid or pudding. Subjects with CP had greater variability and duration of deglutition apnea than controls. Whether the differences seen in breath-swallow pattern and deglutition apnea in young people with CP contribute to aspiration risk remains to be determined. Further clarification of these results by a carefully controlled study of individuals with cerebral palsy undergoing concurrent videofluoroscopic swallowing evaluation and acoustical monitoring of the breath-swallow pattern is required to verify these preliminary results and assess their clinical applicability.

Altered autonomic cardiac regulation in individuals with Down syndrome

We tested the hypothesis that individuals with Down syndrome, but without congenital heart disease, exhibit altered autonomic cardiac regulation. Ten subjects with Down syndrome (DS) and ten gender-and age-matched healthy control subjects were studied at rest and during active orthostatism, which induces reciprocal changes in sympathetic and parasympathetic traffic to the heart. Autoregressive power spectral analysis was used to investigate R-R interval variability. Baroreflex modulation of sinus node was assessed by the spontaneous baroreflex sequences method. No significant differences between DS and control subjects were observed in arterial blood pressure at rest or in response to standing. Also, R-R interval did not differ at rest. R-R interval decreased significantly less during standing in DS vs. control subjects. Low-frequency (LFNU) and high-frequency (HFNU) (both expressed in normalized units) components of R-R interval variability did not differ between DS and control subjects at rest. During standing, significant increase in LFNU and decrease in HFNU were observed in control subjects but not in DS subjects. Baroreflex sensitivity (BRS) did not differ between DS and control subjects at rest and underwent significant decrease on going from supine to upright in both groups. However, BRS was greater in DS vs. control subjects during standing. These data indicate that subjects with DS exhibit reduced HR response to orthostatic stress associated with blunted sympathetic activation and vagal withdrawal and with a lesser reduction in BRS in response to active orthostatism. These findings suggest overall impairment in autonomic cardiac regulation in DS and may help to explain the chronotropic incompetence typically reported during exercise in subjects with DS without congenital heart disease.

Addressing health disparities through promoting equity for individuals with intellectual disability

Intellectual disabilities (ID) are conditions originating before the age of 18 that result in significant limitations in intellectual functioning and conceptual, social and practical adaptive skills. IDs affect 1 to 3% of the population. Persons with ID are more likely to have physical disabilities, mental health problems, hearing impairments, vision impairments and communication disorders. These co-existing disabilities, combined with the limitations in intellectual functioning and in adaptive behaviours, make this group of Canadians particularly vulnerable to health disparities. The purpose of this synthesis article is to explore potential contributory factors to health vulnerabilities faced by persons with ID, reveal the extent and nature of health disparities in this population, and examine initiatives to address such differences. The review indicates that persons with ID fare worse than the general population on a number of key health indicators. The factors leading to vulnerability are numerous and complex. They include the way society has viewed ID, the etiology of ID, health damaging behaviours, exposure to unhealthy environments, health-related mobility and inadequate access to essential health and other basic services. For persons with ID there are important disparities in access to care that are difficult to disentangle from discriminatory values and practice. Policy-makers in the United States, England and Scotland have recently begun to address these issues. It is recommended that a clear vision for health policy and strategies be created to address health disparities faced by persons with ID in Canada.

Therapeutic positioning, wheelchair seating, and pulmonary function of children with cerebral palsy: a research synthesis

This review analyzed research literature concerning pulmonary function and positioning of persons with cerebral palsy (CP) who lack trunk control. The search reviewed literature published from 1966 through March 2003. Twenty-eight references located by electronic database search were analyzed using Moody's Research Analysis Tool. All reflected either a physiologic or therapy-based model involving function in activities of daily living, but no health outcomes. One reference applied a nursing model to care of developmentally disabled persons, including those with CP. Existing research gaps include the need for human subjects, larger sample sizes, measurement of influence of gravity on body position, greater precision in describing independent variables of positioning, and participation by children with disabilities. This paper proposes a conceptual model using Orem's self-care theory upon which to base nursing interventions, including therapeutic positioning of persons with CP who lack trunk control. Future nursing research should explore health outcomes of various properties of wheelchair positioning.

Mental health services use among school-aged children with disabilities: the role of sociodemographics, functional limitations, family burdens, and care coordination

OBJECTIVE

To examine the use of mental health services and correlates of receiving services among community-dwelling children with disabilities, ages 6 to 17 years.

STUDY DESIGN

Data are from the 1994 and 1995 National Health Interview Survey Disability Supplements (NHIS-D), conducted by the National Center for Health Statistics. The study sample is 4,939 children with disabilities, representing an estimated eight million children with disabilities nationwide. Parents of children under 16 years of age reported (17-year-olds self-reported) on health, emotional and behavioral problems, mental health services use, and who, if anyone, coordinated the child's health care.

PRINCIPAL FINDINGS

Among disabled children with poor psychosocial adjustment (11.5 percent), only 11.8 percent received mental health services in the past year. Multivariate logistic regression analysis showed service use was associated with poor psychosocial adjustment; communication, social, and learning-related functional impairments; public health insurance; and financial family burdens. Younger and black disabled children were less likely to receive mental health services. The odds of service use were greater with the involvement of a health professional in coordinating care, in contrast to no one or family only. Moreover, children with disabilities were more likely to use outpatient mental health services if their care was jointly coordinated by a family member and a health professional, compared to a health professional working alone. In contrast to inpatient and outpatient care, race and family burden were not associated with the likelihood of mental health counseling in special education school settings.

CONCLUSIONS

Findings indicate that only two in five disabled children with poor psychosocial adjustment receive mental health services. Differences by age, race, and insurance coverage suggest that inequalities to access exist. However, the school setting may be one in which some barriers to mental health services for disabled children are reduced. The study also shows that the involvement of health professionals in care coordination is associated with greater access to mental health care for disabled children. These findings underscore the importance of engaging both health care professionals and the family in the care process.

Development of bladder control in mentally handicapped children

PURPOSE

To analyze the role of mental handicap as a possible source of lack of development of bladder control and to find out the chance of continence to advise future patients.

MATERIALS AND METHODS

The parents and relatives of 100 consecutive mentally handicapped patients were inquired by a personal interview. Questions included the age when they stopped using diapers, enuretic events, frequency, urgency and leakage episodes, urinary infections. Etiology of their mental problem was unknown in 34, perinatal anoxia in 17, Down syndrome in 15, phenylketonuria in 18 and others minors causes. The grade of mental deficiency were profound in 1, severe in 10, moderate in 39, mild in 33 and normal inferior value in 17. The age varied from 7 to 37 years old, with an average of 14 by the time of the interview, comprising 60 males and 40 females.

RESULTS

All profound and severe patients presented leakage episodes regardless of the age. The mild and normal inferior value acquired progressive urinary control with aging, and 33% still remain with urinary symptoms above 16 years old. Urinary infection was similar in males and females, around 29%. The most committed group presented less urinary infections. The etiology of the mental handicap was not correlated to the incidence of urinary leakage.

CONCLUSIONS

The lack of bladder control was correlated to the grade of mental handicap. In severe and profound groups, the expectancy of control is disappointing. In the less compromised groups, there is a delay in bladder training, with achievement of control in (2/3) after 16 years of age. Those in the normal inferior value have a chance of postponed urinary control, easily misdiagnosed by normal urological interviews.

Survival rates of children with severe neurologic disabilities: a review

Knowledge of accurate survival rates of children with neurologic disabilities is important for third-party insurance payers planning future medical expenses. This is of particular importance to pediatric skilled nursing facilities (SNFs) that depend on financial support from governmental sources. Eyman published survival rate results from California that were extremely pessimistic and not in keeping with our clinical impressions. This led us to conduct a thorough review of our survival rates, which were much better than those reported by Eyman. Since the publication of our study, a large number of reports have appeared from many different countries, as well as further information from California using an expanded database. The survival rate data that we obtained remain consistently better than that in most recent reports. In the California results, 10-year survival rates for the most-disabled group (group 1) were reported to be 32% in 1993 and 45% in 1998, compared with 73% in our study. Eight-year survival rates for group 1 from California were reported to be 38% in 1993 and 63% in 2000, compared with our finding of 73%. The reasons for our better survival rates include the fact that all of our patients were in SNFs, where prompt medical care for acute illnesses was always provided, whereas only 3.5% of the study group was in SNFs in California. Also, the California data contained many methodologic and statistical errors, which are reviewed here.

Androgens and cardiovascular disease

Globally, cardiovascular disease will continue causing most human deaths for the foreseeable future. The consistent gender gap in life span of approximately 5.6 yr in all advanced economies must derive from gender differences in age-specific cardiovascular death rates, which rise steeply in parallel for both genders but 5-10 yr earlier in men. The lack of inflection point at modal age of menopause, contrasting with unequivocally estrogen-dependent biological markers like breast cancer or bone density, makes estrogen protection of premenopausal women an unlikely explanation. Limited human data suggest that testosterone exposure does not shorten life span in either gender, and oral estrogen treatment increases risk of cardiovascular death in men as it does in women. Alternatively, androgen exposure in early life (perinatal androgen imprinting) may predispose males to earlier onset of atherosclerosis. Following the recent reevaluation of the estrogen-protection orthodoxy, empirical research has flourished into the role of androgens in the progression of cardiovascular disease, highlighting the need to better understand androgen receptor (AR) coregulators, nongenomic androgen effects, tissue-specific metabolic activation of androgens, and androgen sensitivity. Novel therapeutic targets may arise from understanding how androgens enhance early plaque formation and cause vasodilatation via nongenomic androgen effects on vascular smooth muscle, and how tissue-specific variations in androgen effects are modulated by AR coregulators as well as metabolic activation of testosterone to amplify (via 5alpha-reductase to form dihydrotestosterone acting on AR) or diversify (via aromatization to estradiol acting upon estrogen receptor alpha/beta) the biological effects of testosterone on the vasculature. Observational studies show that blood testosterone concentrations are consistently lower among men with cardiovascular disease, suggesting a possible preventive role for testosterone therapy, which requires critical evaluation by further prospective studies. Short-term interventional studies show that testosterone produces a modest but consistent improvement in cardiac ischemia over placebo, comparable to the effects of existing antianginal drugs. By contrast, testosterone therapy has no beneficial effects in peripheral arterial disease but has not been evaluated in cerebrovascular disease. Erectile dysfunction is most frequently caused by pelvic arterial insufficiency due to atherosclerosis, and its sentinel relationship to generalized atherosclerosis is insufficiently appreciated. The commonality of risk factor patterns and mechanisms (including endothelial dysfunction) suggests that the efficacy of antiatherogenic therapy is an important challenge with the potential to enhance men's motivation for prevention and treatment of cardiovascular diseases.

Survey of nursing and medical profile prior to deinstitutionalization of a population with profound mental retardation

During the planning stages of deinstitutionalization, the importance of nursing services must be recognized and given priority consideration in the community placement of persons with serious developmental disabilities. The objective of this study was to survey the medical and nursing profile of a group of nonambulatory, institutionalized individuals with profound mental retardation in anticipation of their nursing and medical needs in the community. Data were collected from the Individual Habilitation Plans of 55 individuals who had resided in a residential facility for individuals with mental retardation and were scheduled for community placement Serious medical problems in decreasing frequency were constipation (96%), seizure disorder (70%), poor dental hygiene (67%), cerebral palsy (62%), scoliosis (61%), contractions (41%), aspiration (44%), skin lesions (40%), and dysphagia (22%). Considering the complexity of health issues encountered in this population, adequate nursing and medical planning are critical to the wellness and successful community placement of a population with special needs.

Life care planning

Physicians may be asked to help plan long-term needs of patients with catastrophic injury. It is crucial to know the life expectancy and be intimately familiar with the needs of the disabled person for whom one is planning. This article uses two diagnostic groups as models to illustrate the process: one a spinal cord injured adult and the other a child with cerebral palsy and mental retardation. We provide examples of some of the specific types of needs for these two groups of individuals.

Life expectancy determination

The estimate of life expectancy following a personal injury is probably one of the most important factors in determining the final quantum of damages. It is a calculation fraught with difficulties. This article endeavours to outline some general factors that aid prediction of life expectancy, and also discusses the evidence from the few long-term studies currently available.

Cerebral palsy in Victoria, Australia: mortality and causes of death

OBJECTIVE

To study the causes of death and the characteristics of children with cerebral palsy that had died over a 25-year period in Victoria, Australia.

METHODOLOGY

Names of children that had died were collected from the Victorian Cerebral Palsy Register. Their hospital records were studied and information was gathered about age of death, motor impairment, the presence or absence of associated disabilities and cause of death.

RESULTS

One hundred and fifty-five children had died during the period 1970-95. The majority of children had severe spastic quadriplegia, intellectual disability and epilepsy. The predominant cause of death was pneumonia, although for many children who died at home the cause was unknown.

CONCLUSIONS

Children with cerebral palsy are a diverse group and those with a severe motor deficit have a reduced life expectancy. Lung disease remains an important cause of morbidity and mortality for this group. Further information about the causes of death is needed, particularly for those children that die at home.

Life expectancy of people with intellectual disability: a 35-year follow-up study

A 35-year follow-up study based on a nation-wide population study of the life expectancy of people with intellectual disability (ID) was undertaken. The study population consisted of a total of 60,969 person-years. A prospective cohort study with mortality follow-up for 35 years was used and the life expectancy of people with ID was calculated for different levels of intelligence. Proportional hazard models were used to assess the influence of level of intelligence and associated disorders on survival. People with mild ID did not have poorer life expectancy than the general population and subjects with mild ID did not have lower life expectancy in the first 3 decades of life. In cases with profound ID, the proportion of expected life lost was > 20% for almost all age groups. The female preponderance was manifested from the age of 60 years onwards, 25 years later than in the general population. Respectively, survival between sexes differed less. Epilepsy and/or hearing impairment increased the relative risk of death for all levels of ID. The prevalence of people with ID over 40 years was 0.4%. People with ID now live longer than previously expected, and the ageing of people with mild ID appears to be equal to that of the general population, posing new challenges to health care professionals.

Caring for the patient with mental retardation in the emergency department

There are approximately 6 million individuals with a diagnosis of mental retardation in the United States. Because of deinstitutionalization of patients with mental retardation, coupled with an increase in their life expectancy, emergency physicians are increasingly encountering and managing patients with mental retardation in the emergency department. Many emergency physicians are uncomfortable when interacting with individuals with mental retardation, which often carries over to the assessment and management of these patients in the ED. The purpose of this review is to aid the emergency physician in understanding the patient with mental retardation, their comorbid conditions, and the approach to evaluating and managing these patients in the ED.

Living with cerebral palsy and tube feeding: A population-based follow-up study

OBJECTIVES

To assess the impact of surgically placed feeding tubes on children with severe cerebral palsy (CP) and their families and to determine the survival of these children after initiation of tube feeding (TF).

METHODS

Virtually all children from Nova Scotia who had gastrostomy or jejunostomy procedures between the years 1980 and 1998 and who had been diagnosed with CP were identified. Caretakers of those children who had TF initiated in the last 8 years were evaluated by using a semi-structured interview. Names of children who had not had recent follow-up visits were submitted to the provincial Vital Statistics office to determine whether they had died. Data from patients who were tube-fed between 1980 and 1989 were then used in combination with data from the more recent cases to create a survival curve.

RESULTS

A total of 61 children were identified; 16 had died. Forty of 45 eligible families were interviewed; 90% were pleased with the effect of TF on their child and family life. Negative reports were associated with increased stress related to feeding. Survival rates after gastrostomy and/or jejunostomy were 83% after 2 years and 75% after 7 years.

CONCLUSIONS

In children with severe CF, initiation of TF improved the quality of life for both the child and family in 90% despite frequent minor complications.

Measuring functional status in children with genetic impairments

One of the consequences of genetic impairments in early childhood is their long-term effect on children's developmental skills in communication, learning, and adaptive behaviors. Functional assessment provides families and clinicians with a common language for describing a child's strengths and limitations in self-care (feeding, dressing, grooming, bathing, continence), mobility, and communication/social cognition. The National Center for Medical Rehabilitation Research described a model of disablement that includes five dimensions: pathophysiology, impairment, functional limitations, disability, and societal limitations. Using this framework, along with the Functional Independence Measure for children, the WeeFIM(R), we describe functional strengths and challenges in children with Down syndrome, spina bifida, congenital limb anomalies, congenital heart disease, urea cycle disorders, severe multiple developmental disabilities, and DiGeorge malformation sequence. We also briefly describe several pediatric functional/adaptive assessment instruments used by developmental professionals (Battelle Developmental Inventory, Vineland Adaptive Behavior Scales, Amount of Assistance Questionnaire). By tracking functional status, health professionals can prioritize secondary and tertiary prevention strategies that optimize self-care, mobility, communication, and learning. When functional limitations interfere with the acquisition of these essential skills, family and community support programs can be maximized.

On Miettinen's multivariate confounder score

Consider a regression model for the effect of a treatment on an outcome variable in the presence of potential confounders. It is common to test for main effects and interactions of the treatment variable; if the confounding variables are discrete, one might then compare the treatment groups within strata formed by suitable covariate patterns. An alternative, due to Miettinen, is to stratify according to a "multivariate confounder score" and test for treatment effects within strata. This test has been shown to be flawed, and the method appears largely to have fallen into disuse. Here we show that such stratification nevertheless provides a sound and often useful graphical comparison of treatment and control groups.

Life expectancy of children with cerebral palsy

Risk factors for mortality of young children with cerebral palsy were studied using a sample of 12,709 children aged 0.5-3.5 years with cerebral palsy who had received services from the State of California between 1980 and 1995. The most powerful prognostic factors for survival were simple functional items: mobility and feeding skills. Once these were known, factors such as severity of mental retardation and presence of quadriplegia contributed relatively little. Children with fair motor and eating skills had good survival prospects, with 90% or more reaching adulthood, but those without such skills had much poorer prospects. Among children who were unable to lift their heads, median survival time was 7 additional years for those who were tube fed (n = 557) and 14 years for those fed entirely by others (n = 997). Although a child's approximate survival chances can be assessed from such functional classifications, we indicate the manner in which additional information on the child's condition can be used to obtain more accurate survival data.

Improved disability population estimates of functional limitation among American children aged 5-17

OBJECTIVES

This paper (a) creates and validates measures for population survey data to assess functional limitation in mobility, self-care, communication, and learning ability for school-age American children; (b) calculates rates of functional limitation using these measures, and provides population estimates of the number of children with limitations; and (c) examines these limitations as a function of socioeconomic factors.

METHOD

The study is based on data for children aged 5-17 collected in the 1994 National Health Interview Survey on Disability. Ordinal values are assigned to survey items in the four functional areas and analyzed to produce scales of high reliability. These measures are used to identify within a 95% confidence interval the number of children with these limitations. Ordered logistic regression models measure the effects of functional limitations on disability and societal limitation. Socioeconomic differences are measured with an ordered logistic regression model that predicts severity and comorbidity.

RESULTS

Limitations in learning ability (10.6%) and communication (5.5%) are the most common, with mobility (1.3%) and self-care (0.9%) occurring less often. Six percent of children have one serious functional limitation and 2.0% have two or more serious functional limitations. This corresponds to 4.0 million school-age American children with serious functional limitations. Functional limitation is strongly linked to socioeconomic disadvantage and to residence in single-mother households.

CONCLUSIONS

Future population research should use multiple-item scales for four distinct areas of functional limitation, and a summary that takes into account both severity and comorbidity. The improved estimates of the number of school-age children with functional limitation in this paper may help contribute to a more informed scientific and policy discussion of functional limitation and disability among American school-age children. Future research on the disability process among children must consider the role of socioeconomic disadvantage and family structure.

Delayed gastric emptying affects outcome of Nissen fundoplication in neurologically impaired children

BACKGROUND

Nissen fundoplication (NF) has a relatively high failure rate in neurologically impaired children with gastroesophageal reflux (GER). In 1990 we began to use routine technetium 99m sulfur colloid emptying scans and pyloroplasty with NF for delayed gastric emptying (DGE) in our neurologically impaired patients. The aim of this study was to determine the influence of DGE and pyloroplasty on the outcome of NF in neurologically impaired children.

METHODS

One hundred neurologically impaired children underwent NF by a single surgeon between August 1986 and July 1995. Beginning in January 1990 emptying scans were routinely obtained, and patients with DGE underwent pyloroplasty with NF. Outcome analysis was performed for recurrence/wrap failure and other parameters. Mean follow-up was 5.8 years, with a minimum of 18 months.

RESULTS

DGE was found in 35 (65%) of the 54 children who had emptying scans. All 11 children with normal scans had successful NF without recurrent reflux (100%). Forty (93%) of 43 children who underwent pyloroplasty and NF had successful outcomes. Thirty-eight children underwent NF without evaluation of gastric emptying with success in 30 of them (78.9%). Overall success improved from 34 (83%) of 41 in the first half of the study, when 3 (7%) of 41 children underwent emptying scans, to 55 (93%) of 59 in the second half, when 51 (86%) of 59 of the children underwent emptying scans.

CONCLUSIONS

DGE is common in neurologically impaired children with GER. NF in children with normal gastric emptying has a high probability of success. Pyloroplasty improves the outcome of NF in children with DGE. Neurologically impaired children should be evaluated for DGE before operation for GER.

Gastrointestinal problems in the neurologically impaired child

Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux, with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children. Early recognition of an infant with neurological impairment that is compromising the normal feeding process is crucial. Detailed assessment of the nature of the feeding difficulties will help to predict the anticipated future nutritional needs and will allow decisions to be made about the appropriateness of input from different professionals (speech therapy, dietitians, gastroenterologists). Only when such information has been carefully assembled will rational and directed medical and surgical therapy be possible. Nutritional rehabilitation of disabled children can be associated with increased mortality and morbidity secondary to gastro-oesophageal reflux, retching, dumping syndrome or aspiration. It may also entail an increased work for care givers and increase costs of care. It is therefore necessary to document the impact of such rehabilitation on growth and quality of life for both patient and care giver.

Tubefeeding and mortality in children with severe disabilities and mental retardation

OBJECTIVE

To study the contribution of tubefeeding to mortality for children with severe disabilities and mental retardation. Previous research has suggested an association between tubefeeding and mortality. However, risk has never been determined using population-based data or defined in regard to patient variables.

METHODS

Retrospective analysis of a comprehensive statewide data set comprised of 4921 children with severe disabilities and mental retardation living in community and congregate care settings. The outcome measure was mortality; primary study variables included the presence of a feeding tube, measures of functional independence, type of residence, and medical comorbidity.

RESULTS

There were four findings. First, the use of a feeding tube was associated with virtually every disability. Second, when no study variables were controlled, statistically significant differences in mortality rates were noted between children who were tubefed and those who were not. The relative risk of mortality associated with use of a feeding tube was 2.1. Third, the use of a feeding tube was associated with a reduction in relative risk of mortality in children with tracheostomy (relative risk of mortality: .55). However, this association did not achieve statistical significance. Fourth, when study variables were controlled in a multivariate analysis, feeding tube use was associated with no identifiable increase in mortality among children with very severe disabilities, but was associated with an approximated doubled mortality rate among those with less severe disabilities.

CONCLUSIONS

We hypothesize that the increased mortality associated with tubefeeding may be attributable to a differential increase in pulmonary disease secondary to overly vigorous nutritional maintenance and subsequent aspiration after tube placement. For children with tracheostomy this risk may be reduced. If tracheostomy proves to be associated with a relatively more favorable outcome for tubefeeding, we hypothesize that it would reflect the benefits of tracheostomy in allowing access to the airway for suctioning and ventilation. Given the observed higher mortality rates among the less severely disabled children who are tubefed and the substantial costs associated with tubefeeding, a prospective, controlled study may be clinically indicated, ethically justifiable, and economically warranted.

Medical aspects of ageing in a population with intellectual disability: III. Mobility, internal conditions and cancer

The aim of this study was to assess mobility impairment and morbidity and mortality caused by internal conditions and cancer in an ageing population with mild to severe intellectual disability. Seventy subjects with a mean age of 70 years (range 60-92 years) at initial evaluation, were assessed during a 10-year prospective longitudinal study. As was to be expected, there was a high prevalence of mobility impairment (30% under and 58% over age 75), similar to reports from other ageing populations with intellectual disability, and of related conditions (chronic constipation, pulmonary function loss and urinary incontinence). Overall morbidity and mortality caused by internal disease and cancer might be comparable to that in the general ageing Dutch population, but questions concerning the specific contribution of risk factors will have to be addressed. The lack of or atypical presentation of subjective symptoms was striking. Nevertheless, autopsy outcomes showed that diagnosis in people with intellectual disability can be as accurate as in the general population, if performed actively.

Predictors of mortality in children with severe mental retardation: the effect of placement

OBJECTIVES

This study was undertaken to assess the predictors of mortality in severely disabled children with mental retardation, and to compare risk-adjusted mortality rates for those living in institutions with rates for those living in the community.

METHODS

Statistical analysis was performed on a set of 24,469 person-years, derived from a population of all children with severe mental retardation and a fragile medical condition who are registered with the California Department of Developmental Services. Variables included age, several measures of mobility, the presence or absence of tube feeding, the level of retardation, and certain adaptive skills.

RESULTS

Reduced mobility and the use of tube feeding were associated with a large increase in mortality risk. Own home residence and community care facilities have an estimated 25% higher risk-adjusted odds on mortality than institutions and health facilities.

CONCLUSIONS

The differential mortality in the placements points to a possible effect of quality of care. One consequence of the current trend toward deinstitutionalization may be an increased mortality rate in children with severe developmental disability.

Influence of epilepsy on mortality in mental retardation: an epidemiologic study

PURPOSE

A cohort consisting of all persons with known mental retardation (MR) and living in a Swedish province on December 31, 1985, was followed for 7 years (1987-1992) to study the mortality pattern.

METHODS

A file of the cohort was linked to the cause-of-death pattern of the general population in the study area.

RESULTS

One hundred twenty-four deaths (8.4%) occurred among the 1,478 persons with MR. Thirty deaths (10.1%) occurred among the 296 persons with epilepsy and MR. The standardized mortality ratio (SMR) in those with only MR was significantly increased as compared with that of the general population: 1.6 [95% confidence interval (CI) 1.3-2.0]; MR and epilepsy, 5.0 (CI 3.3-7.5); and MR, epilepsy, and cerebral palsy (CP), 5.8 (CI 3.4-9.7). Mortality was increased both in patients with partial seizures without seizures secondarily generalized (SMR 3.7, CI 1.0-13.6) and in patients with seizures secondarily generalized (5.0, CI 2.3-11.0). The highest mortality occurred in patients who had seizures that were always generalized from the onset: 8.1 (CI 5.7-11.5). Mortality increased with increasing seizure frequency during the year preceding the prevalence date. In patients with epilepsy and MR, pneumonia was the most common cause of death and a seizure was the probable cause of death in 6.7%.

CONCLUSIONS

Epilepsy is associated with a significantly increased mortality in persons with MR. The increase is related to seizure type and seizure frequency. Death in persons with epilepsy and MR is seldom directly due to seizures. Other impairments associated with epilepsy and MR are important causes of death.

Role of ocular involvement in the prediction of visual development and clinical prognosis in Aicardi syndrome

AIMS/BACKGROUND

This study was undertaken to document visual function and acuity in patients with Aicardi syndrome, and to determine whether there is any relation between ocular features of the syndrome exhibited at birth and later visual function.

METHODS

Fourteen patients with Aicardi syndrome, all examined and followed by the same ophthalmologist, were reviewed between 1975 and 1992 and their ocular characteristics and visual acuity described. It was hypothesised that larger lacunae may be associated with poorer clinical outcome and therefore the relation between these two variables was investigated.

RESULTS

Visual acuity as documented by Snellen, Sheridan-Gardner, preferential looking, or pattern visual evoked potential tests was in the normal to low normal range in six eyes of four patients. Visual function correlated significantly with macular appearance. Good visual function was preserved if the fovea appeared normal on funduscopic examination and was uninvolved by lacunae. The size of the largest chorioretinal lacuna also correlated significantly with clinical outcome: patients with large lacunae were more likely to be immobile and to have no language skills.

CONCLUSION

It was concluded that good visual function in patients with Aicardi syndrome may be anticipated if the fovea is normal. Although many patients have severe psychomotor retardation, the presence of predominantly small chorioretinal lacunae may indicate a better prognosis for mobility and language development.

The life-expectancy of persons with cerebral palsy

Survival rates for persons with cerebral palsy were calculated using information from a population-based registry which has been collecting data since 1952. The 30-year survival rate approximates 87 per cent. Adverse factors affecting survival are the type of cerebral palsy (spastic quadriplegia having the worst prognosis), epilepsy and severe or profound mental retardation. The length of time over which the data were collected precludes estimating survival time beyond 30 years.

Medical aspects of ageing in a population with intellectual disability: I. Visual impairment

Visual function of an institutionalized population with intellectual disability, consisting of 70 subjects with a mean age of 70.1 (range 60-92) years at initial evaluation, was assessed during a 10-year prospective longitudinal study. One subject had Down's syndrome and could not be assessed as a result of dementia. Lower visual acuity values were relatively overrepresented as compared to reported data from ageing populations without intellectual disability. In addition, the prevalence of moderate to severe visual impairment was distinctly higher (27.9% in the group studied vs. 0.66% at age 60-69 years to 13% over age 80 in a population without intellectual disability). During follow-up, visual function improved in three out of 61 subjects (4.9%) after cataract surgery, and deteriorated in eight out of 61 subjects (13.1%), even with optimal correction, as a result of cataract and macular degeneration. Causes of excess impairment were congenital or childhood conditions, too-late diagnosis of glaucoma and suboptimal correction of refractive errors in non-cooperative individuals. The present author concludes that it should be possible to reduce excess impairment by an active diagnostic and therapeutic attitude to subjects from a young age onwards.

Aicardi syndrome: natural history and possible predictors of severity

Aicardi syndrome is defined by the clinical triad of infantile spasms, agenesis of the corpus callosum, and pathognomonic chorioretinal lacunae. Almost all patients are girls with severe cognitive and physical handicaps, and epilepsy. Fourteen patients with Aicardi syndrome, seen at The Hospital for Sick Children, Toronto, Ontario, Canada, between 1975 and 1992, were reviewed to document the natural history of the disease and obtain life-table estimates of survival. The relationship between 28 neurologic features present in infancy and clinical outcome, as measured by mobility and cognitive function also was examined. Life-table analysis indicated that the estimated survival rate was 76% at 6 years of age and 40% at 15 years of age. Three of the 14 girls (21%) could walk or crawl and 4 (29%) had some language ability. None of the 28 neurologic features was predictive of ultimate clinical outcome. This information should be discussed with parents of children with Aicardi syndrome.

Life expectancy in children with cerebral palsy

OBJECTIVE

To determine life expectancy of children with cerebral palsy.

DESIGN

Cohort analysis, by means of register compiled from multiple sources of ascertainment, of all children with cerebral palsy born during 1966-84 to mothers resident in Mersey region. Status of children was determined by flagging through NHS central register.

SUBJECTS

1258 subjects with idiopathic cerebral palsy, of whom 1251 were traced and included in analysis.

MAIN OUTCOME MEASURES

Effect of functional ability (ambulation, manual dexterity, and mental ability), sex, birth weight, and gestational age on survival.

RESULTS

20 year survival for whole cohort was 89.3% for females and 86.9% for males. For subjects with no severe functional disabilities 20 year survival was 99% (95% confidence interval 98% to 100%), while subjects severely disabled in all three functional groups had 20 year survival of 50% (42% to 58%). Subjects with birth weight < or = 2500 g had 20 year survival of 92% (89% to 95%), while those with birth weight > 2500 g had survival of 87% (84% to 89%). Subjects with gestational age of > 37 weeks had 20 year survival of 93% (91% to 96%), while those with gestational age > or = 37 weeks had survival of 85% (83% to 88%). Birth weight and gestational age were less predictive of survival than functional disability. Best statistical model used gestational age and number of severe functional disabilities as predictors.

CONCLUSIONS

Life expectancy of this cohort of children with cerebral palsy was greater than has been suggested in some previous studies. This has important implications for social, educational, and health services.

Life expectancy of children in a persistent vegetative state

The persistent vegetative state (PVS) is a state of wakeful unconsciousness occurring in adults and children. Despite preservation of vegetative functions, PVS patients have a shortened life-span, although accurate information concerning this issue remains limited. The survival of children in PVS was examined to determine whether age, etiology of the vegetative state, or type of residence in which the patient lived affected the estimated survival. The data of 155,851 developmentally disabled California state residents were reviewed using the Client Development Evaluation Report (CDER). Criteria from the CDER were selected to define the vegetative state and included: lack of interaction with peers; absence of auditory, visual, and expressive or receptive language function; no hand or arm use; inability to eat, sit, roll over, or lift head; and no bowel or bladder control. There were 847 patients who met these criteria on the initial and follow-up CDERs. A product limit survival model was used to develop survival curves and to calculate the median survival time for patients grouped by age, etiology, and type of residence. Median survival (yrs) for patients who remained in PVS for the following age groups was: < 1 yr: 2.6, 1 < 2 yrs: 4.2, 2-6 yrs: 5.2, 7-18 yrs: 7.0, > or = 19 yrs: 9.9. Median survival based on etiology varied from 3.0 to 8.6 years; no consistent relationship existed between etiology and duration of survival. Survival (yrs) for patients younger than age 18 years based on type of residence included: own home: 4.5, institutions: 5.2, skilled nursing facility/private hospital: 3.2, and other community care facilities: 3.7.(ABSTRACT TRUNCATED AT 250 WORDS)