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Kinsella C, Dunphy A, McCormack S, Wilson C, Bennett AE. Experiences of Parents and Caregivers of Children Who Underwent Gastrostomy Tube Insertion. J Patient Exp 2024; 11:23743735241272225. [PMID: 39176304 PMCID: PMC11339735 DOI: 10.1177/23743735241272225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
Gastrostomy feeding is a route of enteral nutrition for children with feeding difficulties. This study investigated caregiver experiences of the transition to gastrostomy feeding. A survey was administered to caregivers of children <18 years in a major pediatric center in Ireland. Experiences of decision-making, support, and adjusting to tube feeding were examined. Seventy-six caregivers participated. Median satisfaction with the information provided by the hospital was high. Almost half (48%) spoke to another caregiver of a child with a gastrostomy prior to their own child's gastrostomy insertion and most (88%) felt reassured by this. Concerns following insertion included managing the tube and their child's oral intake and feelings about the tube. The oral intake of 83% of children who had some intake prior to gastrostomy insertion did not change or increased following insertion. Most (89%) would make the same decision to insert the tube. Feelings associated with the transition included relief and stress. Gastrostomy tube insertion presents logistical and psychosocial challenges for caregivers. Peer support from other caregivers may alleviate some of these challenges.
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Affiliation(s)
- Ciara Kinsella
- Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, Ireland
- Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ Healthcare Campus, Dublin, Ireland
| | - Aisling Dunphy
- Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, Ireland
| | - Siobhan McCormack
- Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, Ireland
| | - Charlotte Wilson
- Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, Ireland
| | - Annemarie E Bennett
- Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ Healthcare Campus, Dublin, Ireland
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2
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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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3
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Dewan T, Turner J, Lethebe BC, Johnson DW. Gastro-oesophageal reflux disease in children with neurological impairment: a retrospective cohort study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001577. [PMID: 36645746 PMCID: PMC9490596 DOI: 10.1136/bmjpo-2022-001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/06/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To determine the incidence and prevalence of gastro-oesophageal reflux disease (GERD) diagnosis and treatment in children with neurological impairment (NI) along with relationship to key variables. DESIGN This is a population-based retrospective cohort study. SETTING This study takes place in Alberta, Canada. PATIENTS Children with NI were identified by hospital-based International Classification of Diseases (ICD) codes from 2006 to 2018. MAIN OUTCOME MEASURES Incidence and prevalence of a GERD diagnosis identified by: (1) hospital-based ICD-10 codes; (2) specialist claims; (3) dispensation of acid-suppressing medication (ASM). Age, gender, complex chronic conditions (CCC) and technology assistance were covariates. RESULTS Among 10 309 children with NI, 2772 (26.9%) met the GERD definition. The unadjusted incidence rate was 52.1 per 1000 person-years (50.2-54.1). Increasing numbers of CCCs were associated with a higher risk of GERD. The HR for GERD associated with a gastrostomy tube was 4.56 (95% CI 4.15 to 5.00). Overall, 2486 (24.1%) of the children were treated with ASMs of which 1535 (61.7%) met no other GERD criteria. The incidence rate was 16.9 dispensations per year (95% CI 16.73 to 17.07). The prevalence of gastrojejunostomy tubes was 1.1% (n=121), surgical jejunostomy tubes was 0.7% (n=79) and fundoplication was 3.4% (n=351). CONCLUSIONS The incidence of GERD in children with NI greatly exceeds that of the general paediatric population. Similarly, incidence rate of medication dispensations was closer to the rates seen in adults particularly in children with multiple CCCs and gastrostomy tubes. Further research is needed to determine the appropriate use of ASMs balancing the potential for adverse effects in this population.
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Affiliation(s)
- Tammie Dewan
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Justine Turner
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - David W Johnson
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Muto M, Onishi S, Murakami M, Kedoin C, Yano K, Harumatsu T, Yamada K, Yamada W, Kaji T, Ieiri S. Useful traction technique for laparoscopic fundoplication without removing proceeding gastrostomy in a neurologically impaired patient with a body deformity. Asian J Endosc Surg 2022; 15:697-699. [PMID: 35066994 DOI: 10.1111/ases.13028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Severely neurologically impaired patients often require the creation of a gastrostomy when they develop difficulty with oral intake followed by antireflux surgery. We use a traction technique for laparoscopic fundoplication without removing the gastrostomy in such cases. Right lateral traction of the round ligament of the liver and left lateral traction of the stomach body are performed using a needle device. The left liver lobe is elevated with a liver retractor inserted via the epigastrium. This traction technique allows a sufficient surgical field for manipulating forceps to be created in cases with a gastrostomy, enabling fundoplication to be performed safely without removing the gastrostomy.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Chihiro Kedoin
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
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5
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Masui D, Fukahori S, Hashizume N, Ishii S, Higashidate N, Koga Y, Sakamoto S, Tsuruhisa S, Nakahara H, Saikusa N, Tanaka Y. Influence of laparoscopy-aided gastrostomy on gastroesophageal reflux in neurologically impaired patients using multichannel intraluminal impedance pH measurements. Esophagus 2022; 19:360-366. [PMID: 34655356 DOI: 10.1007/s10388-021-00888-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Development of gastroesophageal reflux disease (GERD) after gastrostomy remains debatable. Therefore, this study aimed to evaluate whether laparoscopy-aided gastrostomy (LAG) influence on the occurrence of GERD in neurologically impaired (NI) patients. Furthermore, we investigated whether preoperatively excluding NI patients with GERD can reduce the number of patients requiring subsequent anti-reflux surgery (ARS) after LAG. METHODS This retrospective study included 35 NI patients (median age: 11.0; interquartile range 5.0-23.5 years) who underwent LAG according to our criterion from October 2012 to June 2020 and MII-pH before and after LAG. MII-pH parameters were compared in all patients and among three age groups between before and after LAG. RESULTS There were no significant differences in MII-pH parameters before and 1 year after LAG in all patients, and no patient underwent subsequent ARS. Only one paediatric patient with 64 number of reflux episodes before LAG required subsequent ARS 3 years after LAG. CONCLUSIONS Generally, LAG did not influence the postoperative GERD at 1 year after LAG, and our criteria could reduce the number of patients requiring subsequent ARS. However, paediatric NI patients with higher number of reflux episodes in preoperative MII-pH study may need careful long-term follow-up after LAG.
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Affiliation(s)
- Daisuke Masui
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Naoki Hashizume
- 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
| | - Naruki Higashidate
- 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
| | - Saki Sakamoto
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shiori Tsuruhisa
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Hirotomo Nakahara
- 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
| | - Yoshiaki Tanaka
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.,Division of Medical Safety Management, Kurume University School of Medicine, Fukuoka, Japan
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6
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Maddison J, Taylor J, O'Neill M, Cade J, Hewitt C, Horridge K, McCarter A, Fraser LK, Beresford B. Outcomes for gastrostomy-fed children and their parents: qualitative findings from the 'Your Tube' study. Dev Med Child Neurol 2021; 63:1099-1106. [PMID: 33792913 DOI: 10.1111/dmcn.14868] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 12/20/2022]
Abstract
AIM To identify child and parent outcomes relevant to having a gastrostomy, and to specify outcomes believed to be particularly salient to type of diet (formula vs blended food). METHOD Twenty parents, two children (both 12y), and 41 professionals (dietitians [n=10]; nurses [n=12]; paediatricians [n=12]; speech and language therapists [n=7)]) were recruited. Parents and children were interviewed; professionals participated in focus groups. Children (2-18y) represented included those on formula (n=11), blended-food (n=7), and mixed (n=2) diets. All had been tube-fed for at least 6 months. Neurological, genetic, and metabolic conditions were represented. RESULTS Participants identified a range of children's outcomes relevant to a gastrostomy, including physical health, gastrointestinal symptoms, sleep, and time spent feeding. The children described experiences of exclusion caused by being tube-fed. Time, sleep, and emotional health were regarded as most salient to understanding parents' gastrostomy outcomes. Participants believed type of diet would most likely effect gastrointestinal symptoms, time spent feeding, sleep, and physical health. INTERPRETATION Findings indicate a number of refinements to, and allow further specification of, the current 'initial' core outcome set for tube-fed children. Findings also have implications for choice of outcomes measures. Further qualitative research with children and young people is needed. What this paper adds Sleep is a key outcome for children and parents. Gastrointestinal symptoms and physical health were regarded as outcomes most likely to be affected by type of diet. Well-being and participation were identified as key distal outcomes. Gastrostomies are complex interventions. Further specification of the core outcome set is possible.
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Affiliation(s)
- Jane Maddison
- Social Policy Research Unit, University of York, York, UK
| | - Johanna Taylor
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | - Mark O'Neill
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | - Janet Cade
- Nutritional Epidemiology Group, University of Leeds, Leeds, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Karen Horridge
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Lorna K Fraser
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
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7
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Civan HA, Bektas G, Dogan AE, Ozdener F. Percutaneous Endoscopic Gastrostomy Feeding in Children with Cerebral Palsy. Neuropediatrics 2021; 52:326-332. [PMID: 34192785 DOI: 10.1055/s-0041-1731007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM The prevalence of congenital cerebral palsy (CP) worldwide ranges from 0.15 to 0.4%. CP causes several gastrointestinal complications that inhibit normal eating behavior. This single-center observational study aimed to determine the tolerability and benefits of percutaneous endoscopic gastrostomy (PEG) in pediatric CP patients with malnutrition. MATERIALS AND METHODS The study included 41 pediatric CP patients with malnutrition. All patient data were retrospectively obtained from Bakırköy Dr. Sadi Konuk Research and Training Hospital, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Istanbul, Turkey. In addition to baseline measurements of weight, height, triceps skinfold thickness, 1,25-hydroxyvitamin D3, folate, iron, zinc, vitamin B12, hemoglobin, and mean corpuscular volume, data analyzed included follow-up measurements recorded at 3 and 6 months of PEG (standard polymeric enteral supplementation as 1.0 kcal mL-1). RESULTS There was significant improvement in both height, weight, and triceps skinfold thickness in all patients at 3 and 6 months of PEG (p < 0.05). In terms of blood parameters, there was not significant improvement, except that the number of patients with a low hemoglobin count significantly decreased at 3 and 6 months of (p = 0.022). Moreover, the number of patients with vomiting after PEG also significantly decreased at 3 and 6 months of (p = 0.004). CONCLUSION PEG significantly improves malnutrition in pediatric CP patients and does not cause any major complications. Based on these findings, we think PEG is a beneficial and cost-effective intervention with a high rate of tolerability in pediatric CP patients with malnutrition.
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Affiliation(s)
- Hasret Ayyildiz Civan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bakırköy Dr. Sadi Konuk Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Gonca Bektas
- Department of Pediatric Neurology, Bakırköy Dr. Sadi Konuk Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ali Evrim Dogan
- Nutricia, Advanced Medical Nutrition, Medical Department, Istanbul, Turkey
| | - Fatih Ozdener
- Department of Pharmacology, Bahcesehir University, School of Medicine, Istanbul, Turkey
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8
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Ulman H, Dokumcu Z, Elekberova V, Celtik U, Divarci E, Ozcan C, Erdener A. Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children. Pediatr Surg Int 2021; 37:903-909. [PMID: 33783634 DOI: 10.1007/s00383-021-04891-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children. METHODS Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared. RESULTS There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods. CONCLUSION Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.
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Affiliation(s)
- Hilmican Ulman
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Zafer Dokumcu
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey.
| | - Vusale Elekberova
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Ulgen Celtik
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Emre Divarci
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Coskun Ozcan
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Ata Erdener
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
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9
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De Souza B, Richardson SE, Cohen E, Mahant S, Avitzur Y, Carsley S, Rapoport A. Gastric Flora in Gastrostomy Fed Children with Neurological Impairment on Antacid Medication. CHILDREN (BASEL, SWITZERLAND) 2020; 7:children7100154. [PMID: 33003430 PMCID: PMC7599560 DOI: 10.3390/children7100154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 06/11/2023]
Abstract
This prospective cohort study aimed to: (1) describe types, concentrations and sensitivity profiles of bacteria found in gastric aspirates of neurologically impaired children; (2) compare flora between outpatients and those admitted with aspiration pneumonia; and (3) examine predictors of bacterial colonization. Gastric aspirates from gastrostomy fed, neurologically impaired children on antacid medication were measured for pH and sent for microbiological testing. The outpatient arm included 26 children at their baseline; the inpatient arm included 31 children with a clinical diagnosis of aspiration pneumonia. Descriptive statistics summarized the ecology and resistance patterns of microbial flora. Predictors of total bacterial colonization were explored with linear regression. High concentrations of potentially pathogenic fecal-type bacteria were detected in 50/57 (88%) gastric aspirates. pH was found to be the only predictor of bacterial growth; children with gastric pH ≥ 4 had significantly higher concentrations of aerobic growth, while those with no bacterial growth had a pH < 4. Further studies to evaluate optimal gastric pH, the role of gastric bacteria in causing aspiration pneumonia, and the optimal empiric therapy for aspiration pneumonia are recommended.
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Affiliation(s)
- Bradley De Souza
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (B.D.S.); (E.C.); (S.M.)
| | - Susan E. Richardson
- Division of Microbiology, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Eyal Cohen
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (B.D.S.); (E.C.); (S.M.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Sanjay Mahant
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (B.D.S.); (E.C.); (S.M.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada;
| | - Sarah Carsley
- Department of Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, ON M5G 1M1, Canada;
- The Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Adam Rapoport
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (B.D.S.); (E.C.); (S.M.)
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
- Emily’s House Children’s Hospice, Toronto, ON M4M 0B7, Canada
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10
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Gulla KM, Sahoo T, Sachdev A. Technology-dependent children. Int J Pediatr Adolesc Med 2020; 7:64-69. [PMID: 32642538 PMCID: PMC7335821 DOI: 10.1016/j.ijpam.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Abstract
In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.
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Affiliation(s)
- Krishna Mohan Gulla
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Tanushree Sahoo
- Division of Neonatology, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Sachdev
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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11
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, and St. Jude Children's Research Hospital, Memphis, TN
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12
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Allen J, Molloy E, McDonald D. Severe neurological impairment: a review of the definition. Dev Med Child Neurol 2020; 62:277-282. [PMID: 31237356 DOI: 10.1111/dmcn.14294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 12/30/2022]
Abstract
Severe neurological impairment (SNI) is a term commonly used in the medical literature, though there is no agreed definition. This limits opportunities for research into healthcare needs, treatment opportunities, resource planning, and outcome. We reviewed the literature to establish consistency of use of the term and to place it in the context of other commonly employed terms used to describe children with severe, complex medical needs. Forty-two articles were included for full-text analysis, with 23 including a definition of SNI. Motor impairment, intellectual disability, communication difficulties, and increased care needs were included in the definition in 80%, 70%, 30%, and 13% of papers respectively. Dependence on others for decision-making, chronicity, and distinction between disorders of the central nervous system and peripheral nervous system were less frequently included. There is wide variation in the use of the term SNI. A consensus-based definition of this term would be useful to facilitate future research. WHAT THIS PAPER ADDS: There is inconsistency in use of the term severe neurological impairment (SNI), limiting research efforts. In defining SNI, considerations are mobility, intellectual disability, communication difficulties, and increased care needs. Distinction between acute and chronic, central and peripheral nervous system disorders, and dependence on others for decision-making were less significant.
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Affiliation(s)
- John Allen
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
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13
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Joachim KC, Farid-Kapadia M, Butcher NJ, Chee-A-Tow A, Monsour A, Cohen E, Mahant S, Guttmann A, Offringa M, Maguire J, Hogan A, Major‐Cook N, Oppedisano S, Patel H, Soscia J, Stack N, Van Biervliet S. Core outcome set for children with neurological impairment and tube feeding. Dev Med Child Neurol 2020; 62:201-206. [PMID: 31372989 DOI: 10.1111/dmcn.14326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 12/25/2022]
Abstract
AIM To develop a core outcome set (COS) for evaluating gastrostomy/gastrojejunostomy tube impact in children with neurological impairment. METHOD Healthcare providers/researchers and caregivers rated the importance of candidate outcomes on a 5-point Likert scale. Outcomes rated 'somewhat important' or 'very important' by most (≥85%) respondents were voted on during a consensus meeting. Outcomes that reached consensus for inclusion were ratified and assigned to Outcome Measures in Rheumatology filter core areas. The COS was validated in a separate group of caregivers. RESULTS Twelve outcomes were selected from 120 candidate outcomes to form the COS. These included five 'Life Impact' outcomes, three 'Pathophysiological Manifestations' outcomes, two 'Resource Use' outcomes, one 'Growth and Development' outcome, and one 'Death' outcome. INTERPRETATION We developed an evidence-informed and consensus-based COS for use in studies of gastrostomy/gastrojejunostomy tube feeding in children with neurological impairment. Implementation of this COS will help reduce heterogeneity between studies and facilitate evidence-based decision-making. WHAT THE PAPER ADDS Caregivers, healthcare providers, and researchers ranked the importance of 120 outcomes. Twelve core outcomes were identified as essential to measure in future clinical research studies.
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Affiliation(s)
- Kariym C Joachim
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Mufiza Farid-Kapadia
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Alyssandra Chee-A-Tow
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,CanChild Centre for Childhood Disability Research, Hamilton, Ontario, Canada.,Paediatrics Outcomes Research Team, Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Ontario, Canada.,CanChild Centre for Childhood Disability Research, Hamilton, Ontario, Canada.,Paediatrics Outcomes Research Team, Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Paediatrics Outcomes Research Team, Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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14
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Franken J, Stellato RK, Tytgat SHAJ, Van der Zee DC, Mauritz FA, Lindeboom MYA. Gastro-esophageal Reflux After Laparoscopic Gastrostomy Placement in Children. J Pediatr Gastroenterol Nutr 2020; 70:e41-e47. [PMID: 31978032 DOI: 10.1097/mpg.0000000000002530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Evidence on the influence of gastrostomy placement on gastro-oesophageal reflux disease has been inconsistent. The aim of this study was to investigate the influence of gastrostomy on gastro-oesophageal reflux. METHODS A prospective, longitudinal cohort study was performed including 50 patients who underwent laparoscopic gastrostomy between May 2012 and April 2014. Before and 3 months after surgery 24-hour multichannel intraluminal impedance pH monitoring was performed and caregivers filled out reflux symptom questionnaires. RESULTS Gastro-oesophageal reflux symptoms were present in a comparable number of patients before (44%) and after gastrostomy placement (40%; P = 0.73). Twenty-five of the patients (50%) underwent both the preoperative and postoperative tests and were included in impedance-pH analysis. Acid exposure time (percentage of time with pH below 4) did not change significantly after gastrostomy placement: from 6.2% (3.0-18.1) to 6.1% (2.6-14.9). The number of reflux episodes did not significantly change, for either liquid [mean difference 4.3 (-4.5 to 13.2)] or mixed liquid-gas reflux [mean difference 2.0 (-9.3 to 13.3)]. Before gastrostomy placement, 18 out of 25 patients had pathological reflux (72%) on pH-impedance measurement. In 4 patients, pathological reflux dissolved, whereas 4 patients newly developed pathological reflux. A low preoperative weight-for-height percentile was associated with increased acid exposure after gastrostomy placement. CONCLUSIONS Overall, gastrostomy placement was not associated with an increase in acid exposure on 24-hour multichannel intraluminal impedance pH monitoring. Similarly, the prevalence of gastro-oesophageal reflux-related symptoms did not change after gastrostomy.
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Affiliation(s)
- Josephine Franken
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht
| | - Rebecca K Stellato
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefaan H A J Tytgat
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht
| | - David C Van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht
| | - Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht
| | - Maud Y A Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht
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15
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Nelson KE, Rosella LC, Mahant S, Cohen E, Guttmann A. Survival and Health Care Use After Feeding Tube Placement in Children With Neurologic Impairment. Pediatrics 2019; 143:peds.2018-2863. [PMID: 30679378 DOI: 10.1542/peds.2018-2863] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with neurologic impairment (NI) often undergo feeding tube placement for undernutrition or aspiration. We evaluated survival and acute health care use after tube placement in this population. METHODS This is a population-based exposure-crossover study for which we use linked administrative data from Ontario, Canada. We identified children aged 13 months to 17 years with a diagnosis of NI undergoing primary gastrostomy or gastrojejunostomy tube placement between 1993 and 2015. We determined survival time from procedure until date of death or last clinical encounter and calculated mean weekly rates of unplanned hospital days overall and for reflux-related diagnoses, emergency department visits, and outpatient visits. Rate ratios were estimated from negative binomial generalized estimating equation models adjusting for time and age. RESULTS Two-year survival after feeding tube placement was 87.4% (95% confidence interval [CI]: 85.2%-89.4%) and 5-year survival was 75.8% (95% CI: 72.8%-78.4%). The adjusted rate ratio comparing weekly rates of unplanned hospital days during the 2 years after versus before tube placement was 0.92 (95% CI: 0.57-1.48). Similarly, rates of reflux-related hospital days, emergency department visits, and outpatient visits were unchanged. Unplanned hospital days were stable within subgroups, although rates across subgroups varied. CONCLUSIONS Mortality is high among children with NI after feeding tube placement. However, the stability of health care use before and after the procedure suggests that the high mortality may reflect underlying fragility rather than increased risk from nonoral feeding. Further research to inform risk stratification and prognostic accuracy is needed.
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Affiliation(s)
- Katherine E Nelson
- Pediatric Advanced Care Team and .,Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation and
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; and
| | - Sanjay Mahant
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation and.,CanChild Centre for Childhood Disability Research, Hamilton, Ontario, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation and.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; and.,CanChild Centre for Childhood Disability Research, Hamilton, Ontario, Canada
| | - Astrid Guttmann
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation and.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; and
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16
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Poola AS, Sujka JA, Rentea RM, Fraser JD, St Peter SD. Success of Bolus Gastric Feeding After Fundoplication Among Children Who Require Preoperative Jejunal Feeding. J Laparoendosc Adv Surg Tech A 2018; 28:1117-1120. [PMID: 30207923 DOI: 10.1089/lap.2018.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Management of complicated reflux in infants and children is controversial. Jejunal feedings are used when reflux complications occur with gastric feeds. We sought to determine how successful fundoplication is to allow for return of physiologic gastric feeds in patients requiring jejunal feeds preoperatively. METHODS A retrospective review of patients requiring jejunal feeds before fundoplication between 2010 and 2015 was conducted. RESULTS Two hundred thirteen children underwent fundoplication during the study period. One hundred fourteen (49%) children required preoperative jejunal feeds. Median preoperative jejunal feeding trial was 15 days (interquartile range [IQR] 8-36). After fundoplication, gastric feeds were attempted in all patients. Ninety-one (80%) patients tolerated feeds postoperatively without return of preoperative symptoms. Twenty-one (18%) children developed gastric feeding intolerance and were treated with jejunal feeds at a mean of 8 months postoperatively (range 3-17). Ten (9%) children eventually tolerated intragastric bolus feeds, requiring jejunal feeds for a median duration of 2.3 months (IQR 1-5). There were no differences seen in those who were able to tolerate gastric early after the operation and those who did not. Of the patients who were unable to tolerate bolus gastric feeds during the study, a higher proportion had neurologic impairment and were on jejunal feeds for a longer period of time before fundoplication. CONCLUSION In the majority of patients requiring continuous jejunal feeds to manage complications of reflux, fundoplication allows for transition to gastric bolus feeding.
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Affiliation(s)
- Ashwini S Poola
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Joseph A Sujka
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Rebecca M Rentea
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Jason D Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
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17
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Aumar M, Lalanne A, Guimber D, Coopman S, Turck D, Michaud L, Gottrand F. Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children. J Pediatr 2018; 197:116-120. [PMID: 29655862 DOI: 10.1016/j.jpeds.2018.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine if gastroesophageal reflux disease (GERD) is present at long-term follow-up after percutaneous endoscopic gastrostomy (PEG), and to identify factors associated with the occurrence or aggravation of GERD after PEG placement. STUDY DESIGN This prospective, observational study was conducted in our single tertiary center over a 13-year period (gastrostomy performed from 1990 to 2003 and follow-up to 2015). Every child who underwent PEG in our center (N = 368) from 1990 to 2003 was eligible. GERD was defined by clinical manifestations requiring antisecretory or prokinetic treatment, occurrence of a GERD-related complication, or the need for antireflux surgery. Outcomes among patients without antireflux surgery were also assessed. Multivariate analysis was used to identify factors aggravating GERD after PEG placement. RESULTS A total 326 patients (89%; 56% with a neurologic impairment) were studied with a median follow-up after 3.5 years (range, 2.0-13.5 years). After PEG placement, GERD appeared in 11% of patients and was aggravated in 25% of patients with preexisting GERD. Factors associated with GERD worsening after PEG placement were neurologic impairment and preexisting GERD. Only 53 patients (16%) required antireflux surgery, among whom 22 required surgery in the year after PEG. Neurologic impairment was the only factor significantly associated with the need for antireflux surgery. CONCLUSIONS GERD predominantly remains clinically controlled after PEG placement. Routine antireflux surgery at the time of PEG placement is not justified.
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Affiliation(s)
- Madeleine Aumar
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France.
| | - Arnaud Lalanne
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Guimber
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Stéphanie Coopman
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Turck
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Laurent Michaud
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Frédéric Gottrand
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
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18
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European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment. J Pediatr Gastroenterol Nutr 2017; 65:242-264. [PMID: 28737572 DOI: 10.1097/mpg.0000000000001646] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment. METHODS Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.
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19
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Franken J, Mauritz FA, Stellato RK, Van der Zee DC, Van Herwaarden-Lindeboom MYA. The Effect of Gastrostomy Placement on Gastric Function in Children: a Prospective Cohort Study. J Gastrointest Surg 2017; 21:1105-1111. [PMID: 28424983 PMCID: PMC5486691 DOI: 10.1007/s11605-017-3376-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Unfortunately, postoperative complications such as leakage, feeding intolerance, and gastroesophageal reflux frequently occur. These complications may be due to postoperative gastric dysmotility. Our aim was to evaluate the effect of gastrostomy placement on gastric emptying in children. METHODS A prospective study was performed including 50 children undergoing laparoscopic gastrostomy. Before and 3 months after gastrostomy, assessment was performed using the 13C-octanoic acid breath test, 24-h pH monitoring, and reflux symptom questionnaires. RESULTS Gastric half-emptying time significantly increased from the 57th to the 79th percentile (p < 0.001) after gastrostomy (p < 0.001). Fifty percent of patients with normal preoperative gastric emptying develop delayed gastric emptying (DGE, P > 95) after gastrostomy (p = 0.01). Most patients (≥75%) with leakage and/or feeding intolerance after gastrostomy had DGE after operation. A decrease in gastric emptying was associated with an increase in esophageal acid exposure time (r = 0.375, p < 0.001). CONCLUSION Gastrostomy placement in children causes a significant delay in gastric emptying. Postoperative DGE was associated with gastroesophageal reflux and was found in most patients with postoperative leakage and feeding intolerance. These negative physiologic effects should be taken into account when considering gastrostomy placement in children.
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Affiliation(s)
- Josephine Franken
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands.
| | - Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Rebecca K Stellato
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C Van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - Maud Y A Van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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20
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Kim J, Koh H, Chang EY, Park SY, Kim S. Single Center Experience with Gastrostomy Insertion in Pediatric Patients: A 10-Year Review. Pediatr Gastroenterol Hepatol Nutr 2017; 20:34-40. [PMID: 28401054 PMCID: PMC5385305 DOI: 10.5223/pghn.2017.20.1.34] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/15/2016] [Accepted: 10/23/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE This study was performed to review the outcomes of gastrostomy insertion in children at our institute during 10 years. METHODS A retrospective chart review was performed on 236 patients who underwent gastrostomy insertion from October 2005 to March 2015. We used our algorithm to select the least invasive method for gastrostomy insertion for each patient. Long-term follow-up was performed to analyze complications related to the method of gastrostomy insertion. RESULTS Out of 236 patients, 120 underwent endoscopic gastrostomy, 79 had laparoscopic gastrostomy, and 37 had open gastrostomy procedures. The total major complication rates for endoscopic gastrostomy insertion, laparoscopic gastrostomy insertion, and open gastrostomy were 9.2%, 8.9%, and 8.1%, respectively. The most common major complication was gastroesophageal reflux requiring Nissen fundoplication (3.8%), and other complications included peritonitis (1.3%), hiatal hernia (1.3%), and bowel perforation (0.8%). Gastrostomy removal was successful in 8.6% and 5.0% of patients in the endoscopic and surgical gastrostomy groups, respectively. Gastrocutaneous fistula occurred in 60% of surgically inserted cases, requiring a second operation. CONCLUSION This retrospective study was performed to review the outcome of gastrostomy insertion, as well as to introduce an algorithm that can be used for future cases. Further studies should be conducted to make a consensus on choosing the most appropriate method for gastrostomy insertion.
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Affiliation(s)
- Jiyoung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hong Koh
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Young Chang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Yeong Park
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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21
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Yap BKY, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int 2017; 33:217-228. [PMID: 27889821 DOI: 10.1007/s00383-016-4028-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. METHODS We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. RESULTS We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I 2 = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I 2 = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p < 0.0001, I 2 = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I 2 = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I 2 = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). CONCLUSIONS Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
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Affiliation(s)
- Brendan K Y Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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Laparoscopic Nissen fundoplication mainly reduces the volume of acid reflux and potentially improves mucosal integrity up to the middle esophagus in neurologically impaired children detected by esophageal combined pH-multichannel intraluminal impedance measurements. J Pediatr Surg 2016; 51:1283-7. [PMID: 26906020 DOI: 10.1016/j.jpedsurg.2016.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/06/2016] [Accepted: 01/21/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this study was to evaluate detailed changes of gastroesophageal reflux disease (GERD) in children before and after laparoscopic Nissen fundoplication (LNF) utilizing esophageal combined pH-multichannel intraluminal impedance (pH/MII) measurements. PATIENTS AND METHODS Thirteen patients with neurological impairment, who received laparoscopic Nissen fundoplication (LNF) owing to refractory pathological GERD, were enrolled in this study. 24h pH/MII was conducted in all patients before and one year after LNF. Each parameter of the pH/MII was evaluated and compared each other. RESULTS Both the mean pH index and bolus exposure index after LNF were significantly lower than those before LNF. The mean numbers of total and nonacid reflux episodes after LNF were significantly lower than those before LNF. The mean numbers of total, acid and nonacid proximal reflux episodes after LNF were significantly lower than those before LNF. The mean baseline impedance values from Z3 to Z6 after LNF were significantly higher than those before LNF. CONCLUSIONS The present study provides new insights into the effects of LNF in pediatric patients, which prevents mainly acid reflux episodes from rising to the proximal esophagus, and is expected to improve the mucosal integrity up to the middle esophagus.
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Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics 2016; 138:peds.2015-3967. [PMID: 27365302 DOI: 10.1542/peds.2015-3967] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Mufiza Z Kapadia
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences,
| | - Kariym C Joachim
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Chrinna Balasingham
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Eyal Cohen
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Sanjay Mahant
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Katherine Nelson
- Division of Paediatric Medicine, Institute of Health Policy, Management and Evaluation, and Paediatric Advanced Care Team, Department of Paediatrics, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, and Department of Paediatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
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Influence of replacing percutaneous endoscopic gastrostomy for nasogastric tube feeding on gastroesophageal reflux disease with erosive esophagitis. ADVANCES IN DIGESTIVE MEDICINE 2016. [DOI: 10.1016/j.aidm.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Suksamanapun N, Mauritz FA, Franken J, van der Zee DC, van Herwaarden-Lindeboom MY. Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis. J Minim Access Surg 2016; 13:81-88. [PMID: 27251841 PMCID: PMC5363129 DOI: 10.4103/0972-9941.181776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. METHODS: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. RESULTS: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. CONCLUSIONS: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.
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Affiliation(s)
- Nutnicha Suksamanapun
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Josephine Franken
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Abstract
Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.
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Gantasala S, Sullivan PB, Thomas AG. Gastrostomy feeding versus oral feeding alone for children with cerebral palsy. Cochrane Database Syst Rev 2013; 2013:CD003943. [PMID: 23900969 PMCID: PMC7154382 DOI: 10.1002/14651858.cd003943.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Children with cerebral palsy can be significantly disabled in terms of their ability to suck, chew and swallow. This can lead to significant impairment in feeding and, eventually, to undernutrition. It can also result in aspiration of food into the lungs. Length of feeding time may be considerably increased and, instead of being an enjoyable experience, mealtimes may be distressing for both child and carer. For children unable to maintain a normal nutritional state feeding by mouth, gastrostomy or jejunostomy tubes are increasingly being used to provide the digestive system with nutrients. A gastrostomy tube is a feeding tube inserted surgically through the abdominal wall directly into the stomach. A jejunostomy feeding tube is inserted into the jejunum, part of the small intestine, either directly or via a previous gastrostomy. Although gastrostomy or jejunostomy placement may greatly facilitate the feeding of children with cerebral palsy, many carers find it very emotionally difficult to accept this intervention. Moreover, the intervention is costly and there is the possibility of complications. The effectiveness and safety of the treatment requires further assessment. This review is an update of one previously published in 2004. OBJECTIVES To assess the effects of nutritional supplementation given via gastrostomy or jejunostomy to children with feeding difficulties due to cerebral palsy. SEARCH METHODS For this update, we searched the following databases in July 2012: CENTRAL, MEDLINE , Embase, CINAHL, Science Citation Index, Conference Proceedings Citation Index, LILACS and Zetoc. We searched for trials in ICTRP and Clinicaltrials.gov, and for theses in WorldCat and Proquest Index to Theses. We also contacted other researchers and experts in this field. SELECTION CRITERIA We looked for randomised controlled trials that compared delivery of nutrition via a gastrostomy or jejunostomy tube compared with oral feeding alone for children up to the age of 16 years. DATA COLLECTION AND ANALYSIS Screening of search results was undertaken independently by two review authors. No data extraction was possible as there were no included studies. MAIN RESULTS No trials were identified that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Considerable uncertainty about the effects of gastrostomy for children with cerebral palsy remains. A well designed and conducted randomised controlled trial should be undertaken to resolve the current uncertainties about medical management for children with cerebral palsy and physical difficulties in eating.
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Åvitsland TL, Birketvedt K, Bjørnland K, Emblem R. Parent-Reported Effects of Gastrostomy Tube Placement. Nutr Clin Pract 2013; 28:493-8. [DOI: 10.1177/0884533613486484] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tone Lise Åvitsland
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
- Department of Pediatric Surgery, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjersti Birketvedt
- National Resource Center for Feeding and Nutritional Difficulties in Children, Section for Child Neurology, Oslo University Hospital, Oslo, Norway
| | - Kristin Bjørnland
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Ragnhild Emblem
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
- Department of Pediatric Surgery, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Pemberton J, Frankfurter C, Bailey K, Jones L, Walton JM. Gastrostomy matters--the impact of pediatric surgery on caregiver quality of life. J Pediatr Surg 2013; 48:963-70. [PMID: 23701768 DOI: 10.1016/j.jpedsurg.2013.02.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. METHODS A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2 weeks, 3, 6, 9, and 12 months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). RESULTS A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12 months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57-3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12 months. CONCLUSION Gastrostomy not only improves the child's physical health, but also improves the mental health of the child's caregivers, especially at (or after) one year.
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Affiliation(s)
- Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
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Wallis C, Ryan M. Assessing the Role of Aspiration in Pediatric Lung Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012. [DOI: 10.1089/ped.2012.0148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Colin Wallis
- Respiratory Unit, Great Ormond Street Hospital and the Institute of Child Health, London, United Kingdom
| | - Martina Ryan
- Speech and Language Therapy Department, Great Ormond Street Hospital, London, United Kingdom
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Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol 2012; 47:321-37. [PMID: 22009835 DOI: 10.1002/ppul.21576] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/11/2011] [Indexed: 11/08/2022]
Abstract
Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, St. Jude Children's Research Hospital, Memphis, Tennessee 38103, USA.
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Noble LJ, Dalzell AM, El-Matary W. The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review. Surg Endosc 2012; 26:2504-12. [PMID: 22437953 DOI: 10.1007/s00464-012-2221-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/14/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The relationship between percutaneous endoscopic gastrostomy (PEG) insertion and gastro-oesophageal reflux disease (GERD) is widely disputed in the current literature. The aim of this systematic review is to examine the available evidence documenting the association between PEG and GERD. METHODS The following databases were searched: MEDLINE (1950 to week 2, January 2011), PubMed, ISI Web of Knowledge (1898 to week 2, January, 2011), EMBASE (1980 to week 2, January 2011) and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms "gastroesophageal reflux", "gastroesophageal disease", "GERD", "GERD", "GER", "GER" and "percutaneous endoscopic gastrostomy", "PEG", "gastrostomy". In addition, the reference lists of all included studies were reviewed for relevant citations. Studies examining children pre and post insertion of PEG for GERD and written in English language were included. Data extraction was performed by two authors, and the methodology and statistical analysis of each study were assessed. RESULTS Eight studies were included in this systematic review. Two reported increased incidence of GERD after PEG. However, neither was of high methodological quality. The remaining six reported no change or decreased GERD. Nonetheless, few demonstrated rigorous methodology. CONCLUSIONS The current evidence examining the effect of PEG insertion on GERD has been inconsistent and is not of high quality and therefore is unconvincing, preventing a definitive conclusion. Overall, the available literature on this topic does not demonstrate a causal effect of PEG insertion on GERD.
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Affiliation(s)
- Louise J Noble
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Abstract
The pulmonary involvement concurrent with gastrointestinal (GI) diseases is often clinically subtle. Radiological manifestations might lag behind the respiratory compromise, and only such specialized testing as high resolution computed tomography (HRCT), permeability studies with labelled proteins, or comprehensive pulmonary function tests (PFTs) may be sensitive enough to detect the evolving pathophysiology. Increasing recognition of specific entities, such as immune-mediated alveolitis, will allow implementation of therapies that can significantly improve a patient's prognosis.
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Abstract
Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and minimally invasive surgical method for providing enteral access in children. In pediatrics, the indications for PEG placement frequently include malnutrition or failure to thrive, as well as oropharyngeal dysphagia, especially in children with neurological impairment (NI). The risk for postoperative complications is low. However, among children with NI, gastroesophageal reflux disease (GERD) may necessitate fundoplication prior to gastrostomy tube placement. Preoperative pH probe testing has not been shown to be an effective screening tool prior to PEG placement among patients with GERD. Laparoscopic gastrostomy tube insertion was introduced in pediatric patients in an attempt to decrease complications associated with PEG. Although outcomes were reported to be similar to or better than PEG alone, future comparative studies are needed to better define the optimal patient demographic for this technique.
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Affiliation(s)
- John E Fortunato
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, The Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Kawahara H, Mitani Y, Nose K, Nakai H, Yoneda A, Kubota A, Fukuzawa M. Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired? J Pediatr Surg 2010; 45:2373-6. [PMID: 21129548 DOI: 10.1016/j.jpedsurg.2010.08.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 08/12/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Patients who have advanced neurologic impairment (NI) and require gastrostomy placement (GP) frequently have symptomatic gastroesophageal reflux. We investigated the outcomes of GP without fundoplication in patients who had NI. METHODS This was a retrospective review of 54 patients with NI (median, 7 years; range, 1-18 years) undergoing GP alone. The operative criteria included medically controllable or no reflux symptoms. The patients were divided into 2 groups based on the percentage of total esophageal time with a pH less than 4.0 (reflux index, or RI): group I (GI, n = 33), RI less than 5.0% (median age, 6 years; range, 2-15 years); group II (GII, n = 21), RI 5.0% or greater (median age, 10 years; range, 1-18 years). Data are expressed as medians and ranges. RESULTS Nutritional management was successfully conducted after GP with or without the administration of lansoprazole, famotidine, or rikkunshito in all but 2 patients. One GI patient with alpha-thalassemia required fundoplication, and one GII patient with Cockayne syndrome required gastrojejunal tube feeding. The RI increased significantly in GI patients (2.1% [0%-4.8%] vs 4.5% [0.2%-11.4%], P = .004), whereas it decreased significantly in GII patients (11.2% [5.9%-41.6%] vs 9.8% [1.05-26.6%], P = .04). CONCLUSION Gastroesophageal reflux and related symptoms rarely deteriorate to require additional treatment after GP in patients with NI. Gastrostomy placement is a less invasive and effective procedure for improving the quality of life in those patients.
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Affiliation(s)
- Hisayoshi Kawahara
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodo-cho Izumi, Osaka 594-1101, Japan.
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Trabi T, Dunitz-Scheer M, Kratky E, Beckenbach H, Scheer PJ. Inpatient tube weaning in children with long-term feeding tube dependency: A retrospective analysis. Infant Ment Health J 2010; 31:664-681. [PMID: 28543064 DOI: 10.1002/imhj.20277] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study investigates the outcome of an intervention program to establish oral feeding after prolonged tube feeding in children. The intervention is based on supervised reduction of enteral formula within a few days supported by a 3-week program of speech therapy, occupational therapy, psychoanalytically based eating therapy, physical therapy, psychodynamic coaching, and nutritional counseling of the infant and his or her parents. Two hundred twenty-one cases were included in this study. All patients had been severely ill or were handicapped and had been exclusively fed by tube for most of their lives. The major outcome variable was complete discontinuation of tube feeding with sufficient oral feeding after treatment, defined as the child's ability to sustain stable body weight by self-motivated oral feeding. Two hundred three patients (92%) were completely fed orally after treatment. Tube feeding was discontinued completely within 8 days in mean, and mean in-patient treatment time was 21.6 days. The current method can be used by a trained and experienced team to wean tube-dependent children from prolonged tube feeding. Tube weaning should be addressed from the beginning of tube feeding in all children who are expected to restore oral feeding after the phase of nutritional stabilization. Since successful programs are rare, we were motivated to present our results of this elaborate program in this article.
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Affiliation(s)
- Thomas Trabi
- Medical University of Graz, University Hospital for Children, Graz, Austria
| | | | - Elisabeth Kratky
- Medical University of Graz, University Hospital for Children, Graz, Austria
| | - Hannes Beckenbach
- Medical University of Graz, University Hospital for Children, Graz, Austria
| | - Peter J Scheer
- Medical University of Graz, University Hospital for Children, Graz, Austria
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Wilson M, Gosche J, Bishop P, Liu H, Moore T, Nowicki MJ. Critical analysis of caregiver perceptions regarding gastrostomy tube placement. Pediatr Int 2010; 52:20-5. [PMID: 19419510 DOI: 10.1111/j.1442-200x.2009.02851.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gastrostomy tubes (GT) are often required to safely provide nutrition in children with feeding disorders and aspiration risk. The need for a GT brings with it known risks, complications, and benefits, but caregivers may have unspoken concerns and expectations. The present study was done to assess caregiver concerns, expectations, and satisfaction with GT placement in children. METHODS A two-part retrospective and prospective study was conducted to assess caregiver concerns and expectations related to GT placement, to determine which concerns and expectations came to fruition, and to rate overall satisfaction with the GT. Questionnaires were used to collect data before and after GT placement. A visual analog scale (VAS) score was used to determine degree of concern and satisfaction. RESULTS Sixty-four children (19 retrospective, 45 prospective) completed the study. Concern score by VAS was evenly distributed with a mean value of 47.4 +/- 31.8. Concerns were realized in 25%; expectations were met in 93%. Feeding time decreased following GT placement. Satisfaction was reported as satisfied (23.6%), pleased (16.4%), or very pleased (60.0%). CONCLUSIONS Despite pre-placement concerns, most caregivers reported being pleased with the GT following placement. Concerns that occurred were of minor medical significance. Most expectations were met, in particular improved nutrition. The present study provides insight into caregiver concerns and expectations, and which are likely to occur. This information can be useful when counseling caregivers of children requiring GT.
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Affiliation(s)
- Melissa Wilson
- Divisions of Pediatric Gastroenterology and Nutrition, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
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Saadah OI. Gastro-oesophageal reflux in children with cerebral palsy after percutaneous endoscopic gastrostomy: Any predictors? Arab J Gastroenterol 2009. [DOI: 10.1016/j.ajg.2009.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
BACKGROUND Growth failure and undernutrition complicate the clinical course of girls with Rett syndrome (RTT). These abnormalities are, in part, the consequence of oral motor dysfunction and inadequate dietary intake. OBJECTIVE To determine whether gastrostomy placement for nutritional therapy alters the natural history of growth failure and undernutrition in RTT. HYPOTHESIS We hypothesized that gastrostomy placement for nutritional therapy reverses the decline in height, weight, and body mass index (BMI) z scores in RTT. METHODS Standard stadiometric and anthropometric measures were obtained to derive height, weight, and BMI z scores and estimates of fat-free mass (FFM) and body fat in a cohort of girls (n = 92) with RTT before and after gastrostomy placement. Methyl-CpG-binding protein 2 (MECP2) mutations and the presence or absence of a fundoplication were recorded. RESULTS The differences in height (n = 73), weight (n = 81), and BMI (n = 81) z score slopes before and after gastrostomy placement were 1.31 + 2.06 (P < 0.001), 2.38 +/- 3.18 (P < 0.001), and 3.25 +/- 3.32 (P < 0.001), respectively. FFM and body fat (n = 43) increased after gastrostomy by 41 +/- 27 g/cm height (P < 0.001) and 7.5% +/- 5.7% body weight (P < 0.001), respectively. The differences in height, weight, and BMI z score slopes were similar regardless of the age at which the gastrostomy was placed. The differences in height, weight, and BMI z score slopes, as well as the change in FFM and body fat deposition after gastrostomy placement, did not differ between those who did or did not have a fundoplication and among the classes of MECP2 mutations. CONCLUSION Gastrostomy placement for aggressive nutritional therapy favorably altered the natural history of growth failure and undernutrition in RTT, but did not restore height and weight z scores to birth values, regardless of the age at which surgery occurred and in the presence or absence of a fundoplication.
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40
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Sandler AG. The right to nutrition and hydration: a need for vigilance. INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2009; 47:234-238. [PMID: 19489668 DOI: 10.1352/1934-9556-47.3.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Allen G Sandler
- Special Education, Old Dominion University, Norfolk, VA, USA.
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Sathesh-Kumar T, Rollins H, Cheslyn-Curtis S. General paediatric surgical provision of percutaneous endoscopic gastrostomy in a district general hospital--a 12-year experience. Ann R Coll Surg Engl 2009; 91:404-9. [PMID: 19344554 DOI: 10.1308/003588409x391749] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK. PATIENTS AND METHODS A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic. RESULTS A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5-18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2-7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 'buried bumpers', 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality. CONCLUSIONS We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.
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Affiliation(s)
- T Sathesh-Kumar
- Department of Surgery, Luton and Dunstable Hospital, Luton, UK.
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Symptoms of gastroesophageal reflux disease in severely mentally retarded people: a systematic review. BMC Gastroenterol 2008; 8:23. [PMID: 18547405 PMCID: PMC2435531 DOI: 10.1186/1471-230x-8-23] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 06/11/2008] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently backs up (or refluxes) into the gullet (or esophagus), and it has serious consequences for the quality of life. Usually this is felt as heartburn. Because severely mentally retarded people usually do not utter complaints of heartburn, it requires a high index of suspicion to discover possible GERD. Therefore it is relevant for care professionals such as nurses to have knowledge of those with a higher risk of GERD and of the possible manifestations of GERD. METHODS Using a predefined search method, electronic databases were searched for studies relating the presence of symptoms to the presence of GERD. Relevant data were extracted and the methodological quality of the studies assessed. The results of the included studies were synthesized and conclusions about the level of evidence were drawn. RESULTS Nineteen studies were found relating symptoms to the presence of GERD. Only four were of good methodological quality. The studies were very diverse concerning the studied population, the study method, and the kind of symptoms examined. This makes it difficult to synthesize the results of the studies. There is evidence that patients with cerebral palsy, patients using anticonvulsive drugs, and those with an IQ lower than 35 more frequently have GERD. There is also evidence that vomiting, rumination and hematemesis are associated with a higher risk of the presence of GERD, whereas there is no clear scientific evidence that particular behavior symptoms are indicative for GERD. CONCLUSION The possible manifestations of GERD are many and varied. A guideline will be made for care professionals to aid systematic observation of possible manifestations of GERD.
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Miyazawa R, Tomomasa T, Kaneko H, Arakawa H, Shimizu N, Morikawa A. Effects of pectin liquid on gastroesophageal reflux disease in children with cerebral palsy. BMC Gastroenterol 2008; 8:11. [PMID: 18412980 PMCID: PMC2383913 DOI: 10.1186/1471-230x-8-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 04/16/2008] [Indexed: 11/10/2022] Open
Abstract
Background The use of thickeners is a standard therapy for decreasing episodes of regurgitation or vomiting in infants. However, it remains to be investigated whether thickener is effective for vomiting and/or chronic respiratory symptoms in children with cerebral palsy. Methods We enrolled 18 neurologically impaired children caused by cerebral palsy, with gastroesophageal reflux disease. In the first part of this study (pH monitoring), subjects were randomly allocated to two groups: fed with a high-pectin diet [enteral formula: pectin liquid = 2:1 (v/v)], or a low-pectin diet [enteral formula: pectin liquid = 3:1 (v/v)]. Two-channel esophageal pH monitoring was performed over 48 h. In the second part (clinical trial), subjects were fed a high- or low-pectin diet and non-pectin diet for 4 weeks in a crossover manner. Nurses recorded the feeding volume, number of episodes of vomiting, volume of gastric residue, episodes of cough and wheeze, frequency of using oxygen for dyspnea, and the day when the child could return to school. Cough and wheeze were recorded as a cough-score. Results The median value for the % time pH < 4 at the lower and upper esophagus was significantly decreased with a high-pectin diet [9.2% (6.2–22.6) vs. 5.0% (3.1–13.1); P < 0.01, 3.8% (2.9–11.2) vs. 1.6% (0.9–8.9); P < 0.01 (interquartile range), non-pectin and high-pectin, respectively]. The number of reflux episodes per day and duration of longest reflux were decreased significantly with a high-pectin, but not with a low-pectin diet. The median number of episodes of vomiting decreased significantly with a high-pectin diet [2.5/week (1.0–5.0) vs. 1.0 (1.0–1.5), P < 0.05]. The median cough-score was significantly decreased by both concentrations of pectin [8.5/week (1.0–11.5) vs. 2.0/week (0.0–3.0), fed with a high-pectin diet; 7.0/week (1.0–14.5) vs. 1.0/w (0.0–5.0), fed with a low-pectin diet, P < 0.05]. Conclusion Pectin liquid partially decreased gastroesophageal reflux as measured by eshophageal pH monitoring, and might improve vomiting and respiratory symptoms in children with cerebral palsy. Trial registration ISRCTN19787793
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Affiliation(s)
- Reiko Miyazawa
- Department of Pediatrics and Developmental Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
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Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. ACTA ACUST UNITED AC 2008; 14:128-36. [DOI: 10.1002/ddrr.18] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
PURPOSE Children with cystic fibrosis (CF) have a high prevalence of gastroesophageal reflux disease (GERD). As GERD is associated with chronic respiratory symptoms and feeding problems, fundoplication is often performed in children with CF. Although the outcomes of fundoplication have been described across diverse pediatric groups, there is no published experience with CF. METHODS The records of 25 children with CF who underwent fundoplication in our center were reviewed. Data on symptoms and diagnostic testing results as well as on complications related to fundoplication were collected. Nutritional parameters and pulmonary function were compared before and after fundoplication. RESULTS There was no mortality associated with fundoplication, but 12% had complications that required a subsequent surgical procedure. Whereas 28% were able to discontinue their antireflux medications, 48% developed symptoms of recurrent GERD. Overall, there was no change in body mass index, body mass index percentile, or the slope of forced expiratory volume in 1 second (FEV1) after fundoplication. Children who had an FEV1 of less than 60% predicted at the time of fundoplication exhibited an improvement in FEV1 slope compared to those with FEV1 of 60% or more (+5.3% vs -8.6% per year, P = .004). CONCLUSION The complication rate of fundoplication is similar to what has been reported in large series in children without CF. There is a high rate of recurrent GERD and little apparent benefit for either nutritional or pulmonary outcomes. The observed difference on FEV1 slope, in those with moderate-severe vs mild lung disease, highlights the need to thoroughly evaluate the role of fundoplication in children with CF.
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Affiliation(s)
- R Paul Boesch
- Division of Pediatric Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Ramelli GP, Aloysius A, King C, Davis T, Muntoni F. Gastrostomy placement in paediatric patients with neuromuscular disorders: indications and outcome. Dev Med Child Neurol 2007; 49:367-71. [PMID: 17489811 DOI: 10.1111/j.1469-8749.2007.00367.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Studies of children with neurodevelopmental disorders have shown that receiving nutrition through a gastrostomy can improve clinical outcomes and quality of life. However, there is little information on gastrostomy and its effect in patients with neuromuscular disorders. A retrospective casenote review of all patients with a gastrostomy, followed-up at the Hammersmith Hospital, London, was undertaken to assess the indications for, and outcomes of, gastrostomy placement. Notes for 32 patients (17 males, 15 females) were reviewed (age range 32mo-31y; median age 12y 5mo). We found three main groups of diagnoses: congenital muscular dystrophy (n=15), structural congenital myopathies (n=11), and other neuromuscular disorders (n=6). Two main patterns of feeding problems were identified before gastrostomy: swallowing difficulties, and nutrition and growth problems. The follow-up period after gastrostomy was from 12 months to 19 years (mean 5y). Weight faltering was reversed in 17 out of 22 patients, and height faltering in 9 out of 14, where data were available. Twenty-six patients had a reduced frequency of chest infections. No significant complication of gastrostomy placement was documented. Twenty-eight patients or their families were happy with the results of the gastrostomy. Gastrostomy seems to have a substantial positive impact in patients with neuromuscular disease and feeding difficulties.
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Affiliation(s)
- Gian Paolo Ramelli
- Neuromuscular Unit, Department of Paediatrics and Neonatal Medicine, Imperial College, Hammersmith Hospital, London, UK
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Avitsland TL, Kristensen C, Emblem R, Veenstra M, Mala T, Bjørnland K. Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction. J Pediatr Gastroenterol Nutr 2006; 43:624-8. [PMID: 17130739 DOI: 10.1097/01.mpg.0000229550.54455.63] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is widely used for establishing enteral feeding. The aim of this study was to assess immediate and long-term results after PEG insertion. PATIENTS AND METHODS A total of 121 children were retrospectively reviewed. Median age was 2.4 years (range, 4 months-13.2 years) at the time of PEG insertion. Patient morbidity, indications for PEG, preoperative findings and perioperative complications were registered retrospectively. Parents/caregivers of 85 children were interviewed for long-term results. RESULTS Perioperative complications were seen in 12%. Twenty-four percent died at a median of 15 months (range, 1.5 months-8 years) after PEG. Eighty-five families were interviewed with a median follow-up time of 5.6 years (range, 1-10 years). A substantial majority (94%) of parents/caregivers reported that the PEG had a positive influence on their child's situation, and 98% would have chosen PEG insertion again. Vomiting/retching improved in 61% of the children, and oral intake enhanced in 43%. Stoma-related complications were frequent (73%). The gastrostomy tube was permanently removed at a median of 3 years (range, 7 months-7.3 years) after PEG placement in 25%. Delayed closure of the gastrocutaneous fistula after gastrostomy removal occurred in 48% of them. Time from insertion to removal was not predictive of delayed closure. CONCLUSION PEG is a safe technique for establishing enteral feeding, even in very sick children. Major complications are rare, although most children experience minor stoma-related problems. Parents/caregivers report that the gastrostomy is of great help for themselves and their child.
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Affiliation(s)
- Tone Lise Avitsland
- University of Oslo, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
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Marchand V, Motil KJ. Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2006; 43:123-35. [PMID: 16819391 DOI: 10.1097/01.mpg.0000228124.93841.ea] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Undernutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional comorbidities that affect the neurologically impaired child. Monitoring neurologically impaired children for nutritional comorbidities is an integral part of their care. Early involvement by a multidisciplinary team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional status. Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-related morbidity and mortality.
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Affiliation(s)
- Valerie Marchand
- Department of Pediatrics, University of Montreal, Montreal, Canada
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Sullivan PB, Morrice JS, Vernon-Roberts A, Grant H, Eltumi M, Thomas AG. Does gastrostomy tube feeding in children with cerebral palsy increase the risk of respiratory morbidity? Arch Dis Child 2006; 91:478-82. [PMID: 16446283 PMCID: PMC2082795 DOI: 10.1136/adc.2005.084442] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2005] [Indexed: 01/02/2023]
Abstract
BACKGROUND Children with severe neurological impairment may have significant oral motor dysfunction and are at increased risk of nutritional deficiencies, poor growth, and aspiration pneumonia. Gastrostomy tube feeding is increasingly being used for nutritional support in these children. AIM To examine the occurrence of respiratory morbidity before and after gastrostomy feeding tube insertion in children with severe neurological disabilities. METHODS This study was nested in a longitudinal, prospective, uncontrolled, multicentre cohort study designed to investigate the outcomes of gastrostomy tube feeding in 57 children with severe neurological disabilities. Parents completed a questionnaire prior to (visit 1) and 6 and 12 months (visits 2 and 3) following the gastrostomy, detailing number of chest infections requiring antibiotics and/or hospital admission. RESULTS Mean number of chest infections requiring antibiotics was 1.8 on visit 1 and 0.9 on visit 3. Hospital admissions for chest infections fell significantly from 0.5 to 0.09. CONCLUSION This study provides no evidence for an increase in respiratory morbidity following insertion of a feeding gastrostomy in children with cerebral palsy.
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Affiliation(s)
- P B Sullivan
- Department of Paediatrics, University of Oxford, Oxford, UK.
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50
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Craig GM, Carr LJ, Cass H, Hastings RP, Lawson M, Reilly S, Ryan M, Townsend J, Spitz L. Medical, surgical, and health outcomes of gastrostomy feeding. Dev Med Child Neurol 2006; 48:353-60. [PMID: 16608543 DOI: 10.1017/s0012162206000776] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2005] [Indexed: 11/06/2022]
Abstract
A prospective controlled study with repeated measures before and after surgery examined the medical, surgical, and health outcomes of gastrostomy for children with disabilities at a tertiary paediatric referral centre in the North Thames area, UK. Anthropometric measures included weight, mid-upper-arm and head circumference. Five-day prospective food diaries were completed and data on physical health and surgical outcomes recorded. Seventy-six children participated and underwent gastrostomy (44 males, 32 females; median age 3 y 4 mo, range 4 mo-17 y 5 mo), and 35/76 required an anti-reflux procedure. Categories of disability were: cerebral palsy (32/76), syndrome of chromosomal or other genetic origin (25/76), slowly progressive degenerative disease (11/76), and unconfirmed diagnosis (8/76). Most children had gross motor difficulties (99%) and were non-ambulant (83%). Oromotor problems were identified in 78% of children, 69% aspirated, and 65% were fed nasogastrically before surgery. The mean weight before surgery was -2.84 standard deviation score (SDS; SD 2.21, range -9.8 to 3.4). Two-thirds of children achieved catch-up growth postoperatively: weight-for-age (mean difference 0.51 SDS, 95% CI 0.23-0.79, p=0.001) and mid-upper arm circumference (mean difference 1.12 cm, 95% confidence interval 0.50-1.75, p=0.001). Health gains included a reduction in drooling, secretions, vomiting, and constipation. Major surgical complications were found in 13/74 children. The study provides evidence that catch-up growth and health gains are possible following gastrostomy.
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Affiliation(s)
- G M Craig
- Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, University College London, UK.
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