Gastrostomy matters--the impact of pediatric surgery on caregiver quality of life

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement

BACKGROUND

Disparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children's hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children.

METHODS

Our improvement team implemented a G-tube care bundle (6/2018-9/2019) targeting caregiver preparedness and standardizing care in the pre-, intra-, and post-operative periods. Patients who had G tubes placed between 1/2011-8/2022 were categorized to either pre- or post-intervention groups. Primary outcomes were tracked prospectively. National area deprivation index (ADI) was assigned retrospectively and employed to evaluate social risk. Univariate comparisons were made between pre- and post-intervention groups, and between High ADI (≥80) and Low ADI (<80) subgroups in both pre- and post- intervention periods. We used statistical process control methods to further analyze change over time.

RESULTS

396 children were included (188 pre-intervention, 208 post-intervention). The post-intervention cohort demonstrated a lower rate of outpatient dislodgement at 90 days following G-tube placement (21.3 % vs 10.1 %, p = 0.002) and fewer G-tube-related ED visits per G-tube placed within one year of placement (mean 0.8 visits vs 0.6 visits, p = 0.012). Pre-intervention, children from high ADI neighborhoods had significantly greater healthcare utilization compared to those from lower ADI neighborhoods. Post-intervention, previously statistically significant disparities were no longer present. Outpatient G-tube dislodgements within 90 days were particularly mitigated.

CONCLUSIONS

A longstanding quality improvement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage.

TYPE OF STUDY

Retrospective Comparative Study and Prospective Quality Improvement.

LEVEL OF EVIDENCE

Level III.

Implementation and Qualitative Analysis of Peer Support for New Pediatric Gastrostomy Tube Families

INTRODUCTION

Gastrostomy tube (G-tube) insertion in children has frequent complications, including dislodgment and return to the system, which are associated with emotional burden for caregivers. To address these issues, we developed a peer support program for caregivers of children with new G-tubes and aimed to explore program feasibility and acceptability.

METHODS

The G-tube Buddy Program is a peer support program that pairs an experienced G-tube caregiver with new G-tube caregivers. Between April 2022 and December 2022, seven mentors and 21 mentees participated in the program. Five mentors and ten mentees participated in semi-structured focus groups and interviews. Transcripts were analyzed using both inductive and deductive qualitative methods.

RESULTS

We identified five prominent domains: peer support relationship dynamics; mentor and mentee-specific factors; determinants of program success; mentor and mentee perception of the program; and suggestions for program improvement. These domains encompassed main themes: support consisted primarily of assistance with daily life and social and emotional support; texting was usually the preferred communication method; mentee satisfaction is rooted in humanness, teaching, and generation of hope; mentors participated due to positive feelings regarding helping new caregivers with financial motivation being less important; and, participants perceived the program as a valuable source of support for new caregivers that complements and expands the reach of care they receive from clinical providers.

CONCLUSIONS

A peer support model for families with new G-tubes appears feasible and acceptable from participant perspectives. Responses validate the program's potential to add value to the postoperative care of children with G-tubes and will guide program optimization.

Psychological and social impacts on carers of children with a gastrostomy: a systematic review

To determine the psychological and social impacts of a gastrostomy in childhood on carers and families. A systematic search of OVID, Medline and Embase was undertaken using the subject headings and word variants for 'gastrostomy', 'children' and 'carers'. Studies included were those describing the impact of gastrostomies in children on family and carers, published in English. 564 articles were identified. After exclusion of duplicates, abstract and full text screening, 25 were included. Carer anxiety increases in the period leading up to, and for a short period following gastrostomy insertion. 3-6 months following gastrostomy insertion, anxiety reduced (reduced State-Trait Anxiety Inventory scores), carer quality of life improved (higher Quality of Life Scale scores), and carer satisfaction with the child's gastrostomy increased (improved Satisfaction Questionnaire with Gastrostomy Feeding scores). Reported changes in carer quality of life in the longer term following a child's gastrostomy insertion were mixed. The social and psychological burden on caregivers of a gastrostomy in childhood varies over time. There is evidence that paediatric gastrostomies have positive effects on carers' psychological and social well-being; however, aspects of carers' quality of life remain impaired. Carer education and support are vital to reduce the burden placed on carers.

How Families Manage the Complex Medical Needs of Their Children with MECP2 Duplication Syndrome

MECP2 duplication syndrome (MDS) is a rare, X-linked, neurodevelopmental disorder resulting from the duplication of the methyl-CpG-binding protein 2 (MECP2) gene. The clinical features of MDS include severe intellectual disability, global developmental delay, seizures, recurrent respiratory infections, and gastrointestinal problems. The aim of this qualitative study was to explore how the parents of children with MDS manage their child's seizures, recurrent respiratory infections, and gastrointestinal symptoms, and the impact on them as parents. The data were coded into three categories: (1) complex care needs in the home, (2) highly skilled caregivers, and (3) impact on caregivers and families. Complex 24 h care was required and parents developed complex skillsets to ensure that this was delivered well to their child. The provision of extensive complex medical care in the home had an impact on parent mental and physical health, family dynamics, and finances. This study captures the management of high-burden comorbidities in MDS at home. Investigations into how best to support caregiver wellbeing to reduce their stresses, whilst maintaining optimal child health and wellbeing, are needed.

Role of patient and family engagement in quality improvement for pediatric surgery

In recent decades, the role of quality improvement (QI) in pediatric surgery has grown substantially. Patient and family engagement can help to maximize the impact of QI by enhancing safety and patient outcomes. Yet, broader, systematic efforts to actively involve patients and families in QI initiatives remain a persistent gap in pediatric surgery. To address this gap, we propose an agenda centered on three key goals for future quality improvement efforts: (1) building partnerships with patients and their families; (2) expanding the use of patient-reported outcomes (PROs) and novel, cross-disciplinary research methods; and (3) engaging patients and families consistently across all stages of pediatric surgical care. Fulfilling this agenda will be essential in shifting our mindset to view QI as a collective that involves patients, families, clinicians, and payers in continuous, system-wide opportunities to evaluate and improve care. Actively listening to and collaborating with patients and families may also help renew our focus on narrowing the gap between current practice and the best possible practice for children undergoing surgery.

Gastrostomy tube feeding in epidermolysis bullosa: A multi-center assessment of caregiver satisfaction

BACKGROUND/OBJECTIVES

Gastrostomy tubes (G-tubes) are a feasible intervention for nutritional support in patients with epidermolysis bullosa (EB) who suffer from gastrointestinal involvement. However, some parents may be apprehensive about this surgical intervention. The purpose of this study is to assess caregiver satisfaction and experiences after G-tube insertion in children with EB.

METHODS

Nine institutions sent an anonymous 89-item online questionnaire to caregivers of patients with EB and active G-tubes during an 8-week study period. The questionnaire consisted of eight sections and was formatted with multiple choice, Likert scales, dichotomous scales (yes/no), and free text.

RESULTS

Twenty caregiver surveys were completed. All caregivers were parents (100%). The average age of G-tube placement was 2.7 years (SD: 2.1, range 0-8) and duration of the G-tube utilization was an average of 12.0 years (SD: 7.8, range 1-25). EB subtypes were dystrophic (n = 15/20, 75%), junctional (n = 3/20, 15%), and simplex (n = 2/10, 10%). Almost all caregivers (n = 18/20, 90%) reported high levels of satisfaction with G-tube management (scores > 20 on the modified SAGA-8 scale). More than half of caregivers (n = 12/20, 60%) reported that, retrospectively, they would have desired earlier adoption of the G-tube. Caregivers rated mealtimes as more enjoyable and easier both for themselves and the individual with EB post-G-tube placement.

CONCLUSION

The survey demonstrates a high rate of satisfaction for G-tube use among caregivers of patients with EB across varying ages and household settings. The free-text responses provide unique insight into caregiver's individual experiences regarding G-tubes to be considered for future studies.

Gastrostomy and congenital anomalies: a European population-based study

OBJECTIVE

To report and compare the proportion of children with and without congenital anomalies undergoing gastrostomy for tube feeding in their first 5 years.

METHODS

A European, population-based data-linkage cohort study (EUROlinkCAT). Children up to 5 years of age registered in nine EUROCAT registries (national and regional) in six countries and children without congenital anomalies (reference children) living in the same geographical areas were included. Data on hospitalisation and surgical procedures for all children were obtained by electronic linkage to hospital databases.

RESULTS

The study included 91 504 EUROCAT children and 1 960 272 reference children. Overall, 1200 (1.3%, 95% CI 1.2% to 1.6%) EUROCAT children and 374 (0.016%, 95% CI 0.009% to 0.026%) reference children had a surgical code for gastrostomy within the first 5 years of life. There were geographical variations across Europe with higher rates in Northern Europe compared with Southern Europe. Around one in four children with Cornelia de Lange syndrome and Wolf-Hirschhorn syndrome had a gastrostomy. Among children with structural anomalies, those with oesophageal atresia had the highest proportion of gastrostomy (15.9%).

CONCLUSIONS

This study including almost 2 million reference children in Europe found that only 0.016% of these children had a surgery code for gastrostomy before age 5 years. The children with congenital anomalies were on average 80 times more likely to need a gastrostomy before age 5 years than children without congenital anomalies. More than two-thirds of gastrostomy procedures performed within the first 5 years of life were in children with congenital anomalies.

To Button or Not to Button? Primary Gastrostomy Tubes Offer No Significant Advantage Over Buttons

PURPOSE

Outcomes between primary gastrostomy tubes and buttons (G-tube and G-button) have not been established in pediatric patients. We hypothesized that primary G-tube have decreased complications when compared to G-button.

METHODS

A retrospective review of surgically placed gastrostomy devices from 2010 to 2017 was performed. Data collected included demographics, outcomes and 90-day complications. We divided the patients into primary G-tube and primary G-button.

RESULTS

Of 265 patients, 142 (53.6%) were male. Median age and weight at the time of surgery were 7 months (interquartile range [IQR], 2-44 months) and 6.70 kg (IQR, 3.98-14.15 kg), respectively. Among the groups, G-tube had 80 patients (30.2%) while G-button 185 patients (69.8%). There were 153 patients with at least one overall complication within 90 days postoperative. There was no significant difference in overall complications between groups (G-tube 63.8% vs. G-button 55.7%, p=0.192). More importantly, there were no significant differences in major complications among the groups, G-tube vs. G-button (5% vs. 4%; p=0.455).

CONCLUSION

Primary G-tube offers no significant advantage in overall, minor or major complications when compared to primary G-button.

Gastrostomy tube migration causing gastric outlet obstruction and gastric perforation in children-two case reports

Gastrostomy creation is a common procedure in paediatric surgery. It provides enteral nutrition to patients who cannot achieve adequate nutrition by mouth. Common indications of gastrostomy placement in children include syndromic or neurodevelopmental diseases, severe malformations of the aerodigestive tract, craniofacial abnormalities, and intractable gastroesophageal reflux disease with recurrent aspiration. It is also indicated in patients who suffer from failure to thrive and require extra caloric intake. In contrast to adults, paediatric patients have a weaker ability to complain about problems with their gastrostomy tubes when they occur, in particular when some of these neurological patients are non-communicable. Complications may arise when migration of the catheter goes unnoticed, causing obstruction. Due to the smaller stomach size, thinner gastric wall and narrower gastric outlet in paediatric patients, obstruction from the gastrostomy balloon may result in serious sequelae. Here we present two unusual but serious complications of gastrostomy tubes causing suspected duodenal obstruction and subsequent gastric perforation in paediatric patients, requiring emergency operations. Furthermore, we would like to emphasize the importance of proper gastrostomy tube care and alert the caretakers of the potential sinister complications that can arise. We would also like to take this opportunity to suggest measures to prevent their occurrence.

Point Prevalence of Gastrostomy in a Paediatric Population

OBJECTIVE

The aim of the study was to determine the prevalence of gastrostomy in a paediatric population.

METHODS

A population-based cross-sectional point prevalence study of paediatric gastrostomy was performed. Patients included were ages 0 to 19 years, living within 3 inner-city London boroughs; Southwark, Lambeth, and Lewisham. Patients were identified as having a gastrostomy in situ via Home Enteral Nutrition (HEN) and community nursing databases. Electronic healthcare records were scrutinised to confirm current use of a gastrostomy. The main outcome measures were the point prevalence of gastrostomy in the paediatric population (gastrostomies/100,000 children), primary diagnosis, indication underlying gastrostomy insertion, and age at insertion.

RESULTS

The total population studied was 946,709, of whom 213,920 were of age 0 to 19 years. Of these, 179 had a gastrostomy in situ giving a point prevalence for gastrostomy in the paediatric population of 83.7 (95% confidence interval [CI]: 71.4-96.0)/100,000 children. This varied between age groups: 0 to 4 years: 79.6 (57.3-102.0)/100,000, 5 to 9 years: 116.3 (88.7-143.9)/100,000, 10 to 14: years 87.9 (61.9-113.9)/100,000 and 15 to 19: years 41.4 (22.1-60.1)/100,000. The most common primary diagnoses were neurological disorders (57.1%), and structural abnormalities (16.2%). Unsafe swallow was the most common indication (61%), followed by nutritional or fluid supplementation (28.6%), and behavioural reasons (8.7%). The majority (85.1%) of gastrostomies were inserted under the age of 2 years.

CONCLUSIONS

This is the first UK population-based study of paediatric gastrostomy, identifying a point prevalence of 84/100,000 children. The peak prevalence is in children ages 5 to 9 years. Gastrostomy insertion after a child reaches school age is uncommon.

Laparoscopic Gastrostomy Placement in Children Has Few Major, but Many Minor Early Complications

INTRODUCTION

 Laparoscopic gastrostomy (LAPG) is an increasingly popular alternative to more traditional gastrostomy techniques. This study evaluates early postoperative complications following LAPG and investigates risk factors for gastrostomy complications.

MATERIALS AND METHODS

 Retrospective study of patients <16 years undergoing LAPG from 2005 to 2018. Early postoperative complications (<30 days) were grouped as gastrostomy-related or general and graded according to the Clavien-Dindo classification for surgical complications.

RESULTS

 A total of 104 patients, of which 54 (52%) had neurological impairment (NI), were included. Median age and weight were 1.2 years (1 day-15.2 years) and 8.9 kg (3.4-36), respectively. Operating time was median 37 minutes (19-86) and shorter in the second half of the patients (46 vs. 35 minutes, p = 0.04). A total of 40 (38%) patients experienced 53 gastrostomy-related complications. Of these, seven complications needed surgical treatment; severe leakage (2), too short gastrostomy button (1), feeding difficulties (1), gastric outlet obstruction (1), omentum trapped in umbilical port sutures (1), and suspected fascial defect (1). Stoma infection and granulation tissue were reported in 13 and 12%, respectively. Tube dislodgement occurred in six patients and was managed with bedside reinsertion in all. Gastrostomy-related complications were less frequent in NI patients (46 vs 22%, p = 0.01).

CONCLUSION

 LAPG is a safe procedure with few major complications, but a high rate of minor complications. Operating time declined during the study period, and NI patients had fewer gastrostomy-related complications.

Psychosocial support for families of children with neurodisability who have or are considering a gastrostomy: the G-PATH mixed-methods study

Background

Evidence reviews recommend consistent and structured support for children with neurodisability and their caregivers in care pathways in which professionals recommend a gastrostomy feeding tube. To date, and to our knowledge, no research has shown how these recommendations have been implemented.

Objectives

The objectives were to describe different exemplar models of psychosocial support and provide an estimate of their resources and costs.

Design

This was a mixed-methods study involving (1) a web-based survey, (2) a qualitative, collective case study of psychosocial support provision in four services and (3) an estimate of costs and preference through a willingness-to-pay study.

Setting

Four service configurations in different locations in England and Scotland.

Participants

Participants were staff who responded to a survey (n = 67) and interviewees (staff, n = 58; parents/children, n = 29).

Findings

Psychosocial support was rarely formalised or documented; it was delivered by different members of the multidisciplinary team, rather than by designated staff, and it was often integrated into appointments dominated by clinical care. Parents expressed different needs for support but reported little opportunity to discuss emotional aspects. Psychologists were not routinely involved and, in general, families were underserved by psychosocial services. Professionals constructed families’ need for psychosocial support in terms of their own roles and the management of risk. Mechanisms for integrating and delivering support were identified, including models of care that linked community and tertiary health services and integrated health and education through pooled budgets. Although generally valued by both staff and parents, peer-to-peer parent support was not consistently offered. Barriers included concerns about confidentiality and appropriately matching parents. Parents participated as members of a feeding committee at one site. Three analytical constructs described the provision of psychosocial support: ‘hidden work’, expressing emotional vulnerability and negotiations around risks and values. The cost-of-support study found that there was a mean of 2.25 appointments (n = 8 parents or carers) over the previous 12 months. The cost of health-care professionals’ time spent on providing psychosocial support ranged from £0.00 to £317.37 per child per year, with an average cost of £76.42, at 2017 prices. In the willingness-to-pay study the median rank of enhanced support, involving the opportunity to see a psychologist and parental peers, was significantly higher than that of usual care (n = 96 respondents, both carers and professionals, who completed rating of the service; p < 0.001).

Limitations

It proved difficult to disseminate a national survey, which resulted in a small number of returns, and to cost the provision of psychosocial support, which we designated as ‘hidden work’, owing to the lack of recording in clinical systems. Moreover, estimates were based on small numbers.

Conclusions

Parent interviews and the willingness-to-pay study demonstrated a preference for enhanced psychosocial support. The study suggests that there is a need for services to formally assess families’ needs for psychosocial support to ensure that provision is planned, costed and made explicit in care pathways. Personalised interventions may assist with the targeting of resources and ensuring that there is an appropriate balance in focus on both clinical care and psychosocial support needs in relation to and following treatment.

Future work

More work is needed to develop tools to assess families’ needs for psychosocial support and the effectiveness of training packages to strengthen team competency in providing support.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 38. See the NIHR Journals Library website for further project information.

Caregiver strain on informal caregivers when providing care for older patients undergoing major abdominal surgery: a longitudinal prospective cohort study

Background

Health-care systems nowadays rely on complementary patient care by informal caregivers. The need for, and burden on, informal caregivers will likely increase in the upcoming years. This study aimed to examine the burden on caregivers when providing care for elderly patients undergoing major abdominal surgery.

Methods

A single-centre longitudinal cohort study was conducted between November 2015 and June 2018 in the Amphia hospital in Breda, the Netherlands. Patients aged 70+ undergoing elective surgery for colorectal carcinoma (CRC) or an abdominal aortic aneurysm (AAA) were included in this study. Informal caregiver burden was assessed and compared over time using the Caregiver Strain Index (CSI) at the outpatient clinic visit, at discharge, 2 weeks post-discharge and after 6 and 12 months. The effects of patient- and caregiver-related factors on the experienced caregiver strain were examined.

Results

CSI scores of 248 caregivers were significantly increased at discharge (3.5 vs 2.6; p < 0.001) and 2 weeks post-discharge (3.3 vs 2.6; p < 0.001). After 12 months, scores dropped below baseline scores (1.8 vs 2.6; p = 0.012). The highest strain was observed 2 weeks post-discharge for AAA patients and at discharge for CRC patients. Older age, physical or cognitive impairment and burden of comorbidity were associated with an increased caregiver strain at baseline. Type of surgery was independently associated with the change in mean CSI scores over time; a bigger change in caregiver burden is observed after open surgery.

Conclusion

In the early postoperative period, perceived caregiver strain was significantly increased. Psychological support for caregivers may be advisable, with timing of this support depending on diagnosis and patient-related factors.

Trial registration

This manuscript was retrospectively registered on 05-04-2016 in the Netherlands Trial Register (NTR5932). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932

The Use of a Fixation Dressing to Reduce Complications After Neonatal Gastrostomy Tube Placement

Objective: Gastrostomy tubes (GTs) are one of the most common procedures in neonatal surgery, and their malfunction represents one of the most common complaints in the emergency room and clinic. Complications can occur in up to one-third of patients and include pain, peristomal leak, and infection, but can range in severity. We hypothesize that a preventative strategy employing a GT fixation dressing at the time of operation minimizes these postoperative complications in neonates. Approach: All patients less than 1 year of age who underwent laparoscopic GT placement by a single surgeon in the study period were reviewed. All tubes were secured in place on the external abdominal wall for 2 weeks postoperatively. Demographics and outcomes were evaluated. Results: Fifty-three percent of our cohort were male, and 47% were premature. The most common indication for placement was failure to thrive (59%), and common comorbid conditions were characterized as neurologic (71%), and cardiac (59%). The dressing did not prevent hypertrophic granulation tissue formation, but no patient experienced surgical site infection or device-related pressure injury at 30 and 120 days postoperatively. No patient required reoperation or readmission. Innovation: This simple, one-time, cost-effective fixation dressing has the potential to reduce some of the most common postoperative surgical issues in neonatal patients and can be applied in almost any health care setting. Conclusions: A dressing aimed at tube fixation and immobilization for the first two postoperative weeks averts some of the major complications of GT placement over a standard follow-up period as compared with the literature.

A Prospective, Crossover Survey Study of Child- and Proxy-Reported Quality of Life According to Spinal Muscular Atrophy Type and Medical Interventions

BACKGROUND

Spinal muscular atrophy is an autosomal-recessive, progressive neuromuscular disease associated with extensive morbidity. Children with spinal muscular atrophy have potentially increased life spans due to improved nutrition, respiratory support, and novel pharmaceuticals.

OBJECTIVES

To report on the quality of life and family experience for children with spinal muscular atrophy with attentiveness to patient- and proxy-concordance and to stratify quality of life reports by spinal muscular atrophy type and medical interventions.

METHODS

A prospective, crossover survey study inclusive of 58 children (26 spinal muscular atrophy type I, 23 type II, 9 type III) and their family caregivers at a free-standing Midwestern children's hospital. Twenty-eight families completed the 25-item PedsQL 3.0 Neuromuscular Module. Forty-four participants completed the 36-item PedsQL Family Impact Module and 47 completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire.

RESULTS

The PedsQL Family Impact Module demonstrated significant differences between spinal muscular atrophy types I and II in functioning domains including physical, emotional, social, and family relations (P < .03). Child self-report and proxy report surveys demonstrated significant differences between spinal muscular atrophy types in the communication domains (P < .003). Children self-reported their quality of life higher than proxy report of child quality of life. Gastrostomy tube (P = .001) and ventilation support (P = .029) impacted proxy-reported quality of life perspectives, whereas nusinersen use did not. Spinal surgery was associated with improved parental quality of life and family impact (P < .03).

CONCLUSIONS

The measurement and monitoring of quality of life for children with spinal muscular atrophy and their families represents an implementable priority for care teams.

Health-related quality of life in children after laparoscopic gastrostomy placement

Introduction

A gastrostomy placement (GP) is an established treatment to provide enteral feeding in pediatric patients with feeding difficulties aiming to improve nutritional status and health-related quality of life (HRQoL). The aim of this study was to evaluate HRQoL in children with severe feeding difficulties who have undergone GP.

Materials and methods

A cross-sectional study was performed including 128 patients who had undergone laparoscopic GP (2004–2011). HRQoL was evaluated using the validated Pediatric Quality of Life 4.0 Inventory. Multiple regression analysis was performed to identify predictors of HRQoL.

Results

After a mean follow-up of 4.0 years (interquartile range 2.9–6.2) after GP, mean HRQoL was 53.0 out of 100 (standard deviation 21.1). HRQoL was significantly lower in children with neurologic impairment, with a mean difference of −21.4 points between neurologically impaired and neurologically normal children (p < 0.001). HRQoL was also lower in children with cardiac disease (−19.0 points; p = 0.01) and in children with a history of previous gastrointestinal surgery (−15.2 points; p = 0.03). Feeding through a gastrojejunostomy tube (−33.0 points; p = 0.01) and higher age at the time of operation (−1.2 points per year; p = 0.03) were also associated with lower HRQoL. GP-related complications requiring reintervention were associated with lower HRQoL, although this association was not statistically significant (p = 0.06).

Conclusions

Children with severe feeding difficulty, who have undergone GP, have significantly lower HRQoL compared to a healthy pediatric population. Neurologic impairment, cardiac disease, a history of gastrointestinal surgery, older age, and the need for jejunal feeding through the gastrostomy were predictive of even lower HRQoL.

Enfrentamento e Resiliência Familiar na Tomada de Decisão pela Gastrostomia Infantil

Resumo A indicação do procedimento de gastrostomia em uma criança reverbera em suas famílias como um momento de crise, com a ruptura do padrão de funcionamento familiar. A decisão pela gastrostomia infantil envolve crenças e valores familiares, além de aspectos psicológicos, como o enfrentamento e a resiliência familiar. O objetivo deste estudo foi investigar o enfrentamento e a resiliência familiar de cuidadores de crianças frente à tomada de decisão pela gastrostomia infantil. Quatro cuidadores principais de crianças com indicação para gastrostomia responderam ao Inventário COPE, para avaliar estratégias e estilos de enfrentamento, e a entrevista “Indicadores de Resiliência Familiar”, elaborada para esse estudo. O relato verbal dos cuidadores foi analisado com base nos indicadores de resiliência familiar proposto por Walsh, adotando-se a Análise de conteúdo de Bardin. Os indicadores de resiliência familiar encontrados foram a “Busca em extrair significado da adversidade” e a “Perspectiva positiva”, junto com um enfrentamento caracterizado por maior frequência de estratégias como “ Coping ativo”, “Planejamento”, “Reinterpretação positiva e crescimento”, e “Retorno para a religiosidade”. Esses achados sugerem que as famílias foram capazes de superar os desafios impostos pela gastrostomia infantil e enfrentar as adversidades de forma ativa e planejada, quando reinterpretaram sua experiência atribuindo significados positivos à situação. Concluímos que a tomada de decisão resiliente e positiva pauta-se na negociação dos valores familiares e o saber clínico da equipe de saúde. Destacamos o trabalho empático dos profissionais de saúde com os cuidadores, fortalecendo as potencialidades destes para a sobrevivência e superação dos desafios impostos pela gastrostomia.

Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59–0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.

Swallowing function in pediatric patients with bilateral vocal fold immobility

INTRODUCTION

Infants with bilateral vocal fold immobility (BVFI) often have poor swallow function in addition to potential airway compromise. While there are several reports on BVFI and its effect on patients' airway status, little is known about long term swallow function.

OBJECTIVES

We aim to characterize the swallowing function over time in pediatric patients with bilateral vocal fold immobility.

METHODS

A retrospective review of medical records of infants diagnosed with BVFI at a tertiary care children's hospital between 2005 and 2014 was conducted. Patient demographics, nature and etiology of immobility, laryngoscopy findings, comorbidities, and swallow outcomes at diagnosis and follow-up were recorded. Swallowing outcomes as measured by presence or absence of a gastrostomy tube were compared by etiology, vocal fold status, and normal or developmentally delay using the Fisher's exact test.

RESULTS

110 patients with a diagnosis of vocal fold immobility were identified. Twenty-nine (26%) had BVFI and twenty-three had complete medical records. Etiologies of vocal fold immobility include cardiac related in 13% (3/23), idiopathic in 30% (7/23) prolonged intubation in 26% (6/23) central neurologic in 22% (5/23), trauma in 4% (1/23), and infection in 4% (1/23). Average follow-up time was 44 months (range 5-94 months). Ten patients (56.5%) required a gastrostomy tube at time of diagnosis. Of this cohort who received gastrostomy tubes, three (30%) ultimately transitioned to complete oral feeds. Return of vocal fold mobility did not correlate with swallow function. In those with non-neurologic etiologies, the need for gastrostomy tube at end of follow up was unlikely. There was a statistically significant difference in the percentage of gastrostomy tube-free children at most recent follow up in patients who were normally developed (86%) versus those who were developmentally delayed (33%) (p = 0.02).

CONCLUSION

We characterized the swallowing function of 23 pediatric patients with BVFI. Comorbidities are significant predictors of long term swallow function in patients with BVFI while return of vocal fold function is not.

A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review

CONTEXT

Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting.

OBJECTIVE

To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes.

DATA SOURCES

Medline, Embase, and Cochrane Register databases searched from inception to March 2014.

STUDY SELECTION

Articles examining health outcomes of neurologically impaired children living with feeding tubes.

DATA EXTRACTION

Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development.

RESULTS

We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes.

LIMITATIONS

We were unable to investigate effect size of outcomes because quantitative data were not collected.

CONCLUSIONS

The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.

Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement

OBJECTIVES

To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals.

STUDY DESIGN

This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course.

RESULTS

Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission.

CONCLUSIONS

GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.

Caretaker Quality of Life in Rett Syndrome: Disorder Features and Psychological Predictors

OBJECTIVE

Rett syndrome is a severe neurodevelopmental disorder affecting approximately one in 10,000 female births. The clinical features of Rett syndrome are known to impact both patients' and caretakers' quality of life in Rett syndrome. We hypothesized that more severe clinical features would negatively impact caretaker physical quality of life but would positively impact caretaker mental quality of life.

METHODS

Participants were individuals enrolled in the Rett Natural History Study with a diagnosis of classic Rett syndrome. Demographic data, clinical disease features, caretaker quality of life, and measures of family function were assessed during clinic visits. The Optum SF-36v2 Health Survey was used to assess caretaker physical and mental quality of life (higher scores indicate better quality of life). Descriptive, univariate, and multivariate analyses were used to characterize relationships between child and caretaker characteristics and caretaker quality of life.

RESULTS

Caretaker physical component scores (PCS) were higher than mental component scores (MCS): 52.8 (9.7) vs 44.5 (12.1). No differences were demonstrated between the baseline and 5-year follow-up. In univariate analyses, disease severity was associated with poorer PCS (P = 0.006) and improved MCS (P = 0.003). Feeding problems were associated with poorer PCS (P = 0.007) and poorer MCS (P = 0.018). In multivariate analyses, limitations in caretaker personal time and home conflict adversely affected PCS. Feeding problems adversely impacted MCS.

CONCLUSIONS

Caretaker quality of life in Rett syndrome is similar to that for caretakers in other chronic diseases. Disease characteristics significantly impact quality of life, and feeding difficulties may represent an important clinical target for improving both child and caretaker quality of life. The stability of quality-of-life scores between baseline and five years adds important value.

A systematic review and meta-analysis of gastrostomy insertion techniques in children

BACKGROUND

Gastrostomy tubes are inserted via multiple techniques to provide a route for enteral feeding in the pediatric population. This review compares the rate of major complications and resource utilization associated with the various insertion techniques.

METHODS

Major electronic databases were queried for comparative studies of two or more insertion techniques, including open, laparoscopic, percutaneous endoscopic, or fluoroscopic guided. Major complications were defined as reoperation within 1 year or death. Screening of eligible studies, data extraction, and assessment of methodological quality were conducted independently by two reviewers. Forest and funnel plots were generated for outcomes using Revman 5.1, with p<0.05 considered significant.

RESULTS

Twenty-two studies with a total of 5438 patients met inclusion criteria. No differences in major complications were noted in studies comparing open versus laparoscopic approaches or open versus PEG. Studies comparing laparoscopic gastrostomy and PEG revealed a significantly increased risk in major complications with PEG (n=10 studies, OR 0.29, 95% CI: 0.17-0.51, p<0.0001). The number needed to treat to reduce one major complication by abandoning PEG is 45.

CONCLUSIONS

PEG is associated with an increased risk of major complications when compared to the laparoscopic approach. Advantages in operative time appear outweighed by the increased safety profile of laparoscopic gastrostomy insertion.

Prenatally-counseled congenital diaphragmatic hernia parents exhibit positive well-being before and after surgical repair

BACKGROUND/PURPOSE

The purpose of this paper was to examine the effect of prenatal counseling in the Advanced Fetal Care Center (AFCC) on the well-being of parents of infants with congenital diaphragmatic hernia (CDH).

METHODS

From 2008 through 2012, 26 mothers and fathers of surgically repaired CDH patients who received prenatal counseling at our institution, and 15 who received no prenatal counseling, each completed the Short-Form 36 version 1 (SF-36v1) at the appropriate time points: prenatal, two weeks, and six months post-surgery.

RESULTS

Parents in both groups did not differ by demographic characteristics. Patients who received prenatal counseling had significantly longer ventilatory time and length of stay (LOS) in the ICU and in the hospital compared to those who did not receive prenatal counseling (all P<.01). Mothers and fathers had similar SF-36v1 mental and physical component summary (MCS, PCS) post-surgery scores when compared by counseling status. Prenatal MCS scores for mothers and fathers (47 vs. 41; P=.24) were similar to those at six months post-surgery (47 vs. 47; P=.90).

CONCLUSIONS

When hospital LOS was controlled between groups stratified by AFCC counseling status, MCS scores were comparable prenatally and were sustained at six months post-surgery for both parents. These findings may reflect the support services parents received beginning in the prenatal period.