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Nelson KE, Finlay M, Huang E, Chakravarti V, Feinstein JA, Diskin C, Thomson J, Mahant S, Widger K, Feudtner C, Cohen E. Clinical characteristics of children with severe neurologic impairment: A scoping review. J Hosp Med 2023; 18:65-77. [PMID: 36484088 PMCID: PMC9829450 DOI: 10.1002/jhm.13019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies. METHODS Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics. RESULTS We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials. CONCLUSIONS Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.
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Affiliation(s)
- Katherine E Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Finlay
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Emma Huang
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vishakha Chakravarti
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Catherine Diskin
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sanjay Mahant
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eyal Cohen
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
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Fukahori S, Asagiri K, Ishii S, Tanaka Y, Kojima SI, Saikusa N, Koga Y, Yoshida M, Masui D, Komatsuzaki N, Seki Y, Yagi M. Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH–multichannel intraluminal impedance measurements. Pediatr Surg Int 2013; 29:545-51. [PMID: 23519548 PMCID: PMC3657348 DOI: 10.1007/s00383-013-3295-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) in patients with neurological impairment (NI) has not been fully studied before and after fundoplication procedure because their characteristics such as generalized gastrointestinal dysmotility, non-acid reflux, and the proximal reflux due to feeding of enteral nutrition via a nasogastric tube prevent their GERD from being detected by 24 h pH monitoring. The aim of this study was to elucidate whether multichannel impedance-pH measurement (pH/MII) is able to detect the subtypes of GERD and the differences in the reflux episodes of the severity of GERD, the ingestion pathway, and before and after fundoplication. The second aim was to determine whether a trial evaluation of dry swallows was able to be used to assess the esophageal motility of NI patients as an alternative examination. PATIENTS AND METHODS The 24 h pH/MII was conducted on 20 NI children [15 were the patients before Nissen's fundoplication (BN), of whom, six were fed orally (FO) and nine were fed via nasogastric tube (NGT), and five were the patients after Nissen's fundoplication (AN)]. All reflux episodes were evaluated and compared between patients with pathological GERD (PG) and non-pathological GERD (NG) and between patients who had FO and NGT and patients between BN and AN. Dry swallows were conducted to evaluate the esophageal motility. The average bolus presence time (BPT) and total bolus transit time (TBTT) were compared between the PG and NG, FO and NGT, and the BN and AN subgroups. RESULTS A total of 1,064 reflux episodes were detected by pH/MII. Of those, 303 (28.5 %) were non-acid-related and 477 episodes reached the proximal esophagus. Of the 12 patients (57.1 %) showing pathological GERD, two cases (16.7 %) demonstrated predominantly weakly acidic PG. More than half of the reflux episodes of PG patients reached to the proximal esophagus. The numbers of total reflux and proximal reflux episodes in the PG were significantly higher than those in NG patients. The number of proximal reflux episodes in the FO group was significantly higher than that in the NGT groups, whereas NGT patients showed more non-acidic reflux episodes than FO patients. A trial evaluation of dry swallows demonstrated no significant differences in this study. CONCLUSION The pH/MII was useful to detect the subtype of GERD in NI patients which could not be detected by 24 h pH monitoring. It can, therefore, be considered to have first priority for testing NI patients who are suspected to be suffering from GERD.
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Affiliation(s)
- Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Kimio Asagiri
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Shinji Ishii
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Yoshiaki Tanaka
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Shin-ichiro Kojima
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Nobuyuki Saikusa
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Yoshinori Koga
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Motomu Yoshida
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Daisuke Masui
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Naoko Komatsuzaki
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Yoshitaka Seki
- Department of Pediatrics, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan
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Pensabene L, Miele E, Del Giudice E, Strisciuglio C, Staiano A. Mechanisms of gastroesophageal reflux in children with sequelae of birth asphyxia. Brain Dev 2008; 30:563-71. [PMID: 18328656 DOI: 10.1016/j.braindev.2008.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 01/21/2008] [Accepted: 01/30/2008] [Indexed: 11/17/2022]
Abstract
UNLABELLED Patterns of childhood gastroesophageal reflux (GER) have been studied extensively; however, the mechanisms underlying its occurrence in neurologically impaired children (NIC) are poorly understood. Concurrent esophageal manometry and pH monitoring was conducted in 10 un-operated children (7 male; mean age: 59.5 months) with sequelae birth asphyxia and esophagitis. Reflux episodes were scored when esophageal pH decreased to <4 for at least 5 s. When the rate of decrease of lower esophageal sphincter (LES) pressure was >1 mmHg/s, the decrease of LES pressure was defined as LES relaxation. The time relationship of the pharyngeal manometric swallowing signal to LES relaxation onset was then evaluated in order to distinguish between LES relaxations associated with swallowing (type II or III, associated with one or more swallows, respectively) and those that occurred independently of swallowing (type I). RESULTS Esophageal manometry and pH monitoring were conducted for a mean duration of 91.5 min. Basal LES pressure averaged (+/-SD) 9.2+/-4.8 mmHg; in 4 of 10 patients (40%) the LES pressure was largely undetectable, varying between 0 and 2 mmHg. Mean LES pressure was inversely correlated with age (r=0.7, P=0.02). The total number of reflux episodes/h averaged 32.1+/-12.1 LES pressure reached 0 mmHg in 98% of reflux episodes. Type I LES relaxations were present in 3.15+/-1.1 reflux episodes/h, whereas type II LES relaxation occurred in 2.3+/-2.4 episodes/h. Acid reflux episodes appeared during absent basal LES tone periods, without phasic LES relaxations, in 74%. CONCLUSIONS Absent basal LES tone is the main mechanism of GER in a subgroup of NIC, especially in older children. Transient LES relaxation, the most common known event associated with acid reflux in neurologically normal children, seems to precede a minority of reflux events in NIC.
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Affiliation(s)
- Licia Pensabene
- Department of Pediatrics, University Magna Graecia of Catanzaro, Italy
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication. Acta Paediatr 2007; 96:87-93. [PMID: 17187611 DOI: 10.1111/j.1651-2227.2006.00005.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz, Graz, Austria.
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