Percutaneous endoscopic gastrostomy without an antireflux procedure in neurologically disabled children

Interventions for Feeding and Swallowing Disorders in Adults with Intellectual Disability: A Systematic Review of the Evidence

Feeding and swallowing disorders are prevalent in adults with Intellectual Disability (ID) and can potentially lead to discomfort, malnutrition, dehydration, aspiration, and choking. Most common interventions include: diet modification, compensatory strategies, swallowing therapy, and non-oral feeding. Despite their common use, the research evidence for these interventions is lacking. The current study aimed to systematically review the evidence for the safety and the effectiveness of interventions for feeding and swallowing disorders in adults with ID. Seven electronic databases, conference proceedings, and reference lists of relevant studies were reviewed from online availability to March 2019, with no language restrictions. Eligibility criteria encompassed experimental or non-experimental study design, adults (> 18 years) with ID and feeding and/or swallowing disorders (any etiology and severity) and any intervention for feeding and/or swallowing disorders. Methodological quality was assessed by two independent reviewers using the Downs and Black checklist. Four articles met the inclusion criteria. All included studies considered enteral feeding as an intervention strategy and had a retrospective observational design. Overall, included studies reported positive change in nutritional status and a high incidence of adverse events following enteral feeding initiation. Risk of bias was high with variability in methodological quality. The safety and effectiveness of interventions for feeding and swallowing in adults with ID is unclear. This review highlights the lack of evidence-based practice in this area. Directions for further research are provided. Before enteral feeding initiation, risks and benefits should be appropriately balanced on an individual basis, and caregivers should be involved in the decision-making process.

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

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.

The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review

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.

Outcomes of percutaneous endoscopic gastrostomy in children

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.

Pulmonary care of children and adolescents with developmental disabilities

Caring for children and adolescents with developmental disabilities is challenging because of their susceptibility to varying degrees of respiratory morbidity and mortality. This article discusses the common pulmonary problems affecting children with developmental disabilities. Topics to be discussed include gastroesophageal reflux, drooling, and dysphagia and their relation to aspiration and aspiration pneumonia, upper airway obstruction and obstructive sleep apnea, and the role of airway clearance. Case studies are used to introduce a discussion of the underlying etiology, currently accepted methods to evaluate the conditions, and evidence-based treatment options. The goal of managing these problems is to use anticipatory guidance when possible and choose therapies that improve the child's quality of life with minimal side effects.

Is there a connection between severe cerebral palsy and increased gluten sensitivity?

In nine children with severe cerebral palsy (CP), feeding difficulties and poor development of weight and height, laboratory markers for metabolic and enteral dysfunction were studied.

CONCLUSION

Four of the nine patients with CP had increased levels of antigliadin antibodies AGA (IgA), a finding which calls for further studies concerning the possible connection between increased celiac markers and CP.

Endoscopic gastrostomy placement in the child with gastroesophageal reflux: is concomitant antireflux surgery indicated?

BACKGROUND/PURPOSE

Previously, we performed concomitant antireflux surgery in patients with abnormal pH study undergoing gastrostomy. This increased complications without always alleviating the troublesome symptom of vomiting. In contrast, vomiting with normal preoperative pH study generally disappeared after gastrostomy placement. Therefore, we changed policy to perform only gastrostomy, regardless of pH study results. Subsequent antireflux surgery is performed only as necessary. We report here our results.

METHODS

We retrospectively reviewed patients undergoing gastrostomy from April 1997 to January 2004. For patients with abnormal preoperative pH studies, detailed data were recorded including medical history, indication for gastrostomy, operative technique, symptoms of gastroesophageal reflux (GER), and use of antireflux medication. Symptomatic GER postgastrostomy was managed pharmacotherapeutically. If this proved inadequate, patients underwent antireflux surgery.

RESULTS

Twenty-eight patients with abnormal pregastrostomy pH study entered the study. Median age was 3 years and 2 months. Seventy-five percent were neurologically impaired. Indication for gastrostomy was inadequate oral nutrition in 26 of 28 patients. Only 3 of 28 patients were asymptomatic for GER. Of the 25 symptomatic patients 19 improved postgastrostomy (6 did not). Antireflux surgery ultimately proved indicated in 2 patients (7% [2/28]). The asymptomatic patients remained asymptomatic.

CONCLUSIONS

For patients with abnormal pH study presenting primarily for gastrostomy placement, concomitant antireflux surgery is not indicated.

Does gastrostomy tube feeding in children with cerebral palsy increase the risk of respiratory morbidity?

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.

Effect of Gastrostomy on Growth in Children with Neurodevelopmental Disabilities

Chronic malnutrition and growth failure are frequent consequences of feeding difficulties in neurodevelopmentally disabled children. Gastrostomy feeding has been used successfully to alleviate chronic malnutrition as well as distress and frustration associated with feeding. Unfortunately, caregivers are often resistant to gastrostomy placement. In order to determine the impact of gastrostomies in 20 children with neurodevelopmental disability (NDD), a questionnaire was used to collect caregivers’ perceptions both before and after gastrostomy. The questionnaire assessed caregivers’ retrospective perceptions of quality of life, feeding difficulties, and the burdens and benefits of gastrostomies. To determine impact on growth, height and weight were measured once before and three times after gastrostomy (at six, 12, and 24 months). The number of times a child was fed and the amount of time spent feeding decreased significantly following gastrostomy (p<0.001 and p<0.05, respectively). Growth for all children improved following gastrostomy (p<0.001). Pregastrostomy problems improved significantly following gastrostomy, as did caregivers’ perceptions of quality of life for both themselves and their child (p<0.001). These results indicate that gastrostomy has a positive impact on growth for neurodevelopmentally disabled children, and on quality of life for both children and caregivers. Caregivers may find these results encouraging if they are faced with a decision about gastrostomy placement for their child.

Feeding method and health outcomes of children with cerebral palsy

Disorders of feeding and swallowing are common in children with cerebral palsy. Feeding and swallowing disorders have significant implications for development, growth and nutrition, respiratory health, gastrointestinal function, parent-child interaction, and overall family life. Assessments need to be comprehensive in scope and centered around the medical home. Oral feeding interventions for children with cerebral palsy may be effective in promoting oral motor function, but have not been shown to be effective in promoting feeding efficiency or weight gain. Feeding gastrostomy tubes are a reasonable alternative for children with severe feeding and swallowing problems who have had poor weight gain.

Percutaneous endoscopic gastrostomy: the technique of choice?

BACKGROUND/PURPOSE

The percutaneous endoscopic gastrostomy (PEG) is contested on the ground that it could cause gastroesophageal reflux (GER). The authors studied the complications of PEG to ponder the validity of this contraindication.

METHODS

The authors followed up with a group of 81 patients subjected to PEG to assess their complications, GER in particular.

RESULTS

In half of the patients, PEG was performed under deep sedation in the intensive care unit and the other half under general anesthesia. The procedure lasted about 12 minutes in both subgroups. Early complications were not observed. Late complications relating to the care of the tube were similar to those reported for other techniques. GER appeared in 8%, but surgical treatment was unnecessary, whereas in patients that presented GER before surgery, it subsided in 38%. A colocutaneous fistula observed in one patient was a consequence of previous interventions.

CONCLUSIONS

PEG is minimally invasive, general anesthesia may be avoided, the procedure is rapid, major complications are conspicuously absent, and the incidence of GER is smaller than that associated with alternative techniques. In addition, the cost is low. The authors consider PEG the technique of choice because it has important advantages compared with open or laparoscopic techniques.

Diagnosis and treatment of feeding disorders in children with developmental disabilities

OBJECTIVES

To determine the results of diagnostic evaluation and the effects of nutritional intervention on energy consumption, weight gain, growth, and clinical status of children with neurodevelopmental disabilities and suspected feeding disorders.

METHODS

We studied 79 children with moderate to severe motor or cognitive dysfunction (male:female, 38:41; age, 5.8 +/- 3.7 years) who were referred for diagnosis and treatment of feeding or nutritional problems. Initial assessments included a 3-day calorie intake record, videofluoroscopic swallowing study (VFSS), 24-hour intraesophageal pH monitoring, milk scintigraphy, and esophagogastroduodenoscopy.

RESULTS

These studies demonstrated gastroesophageal reflux (GER) with or without aspiration in 44 of 79 patients (56%), oropharyngeal dysphagia in 21 (27%), and aversive feeding behaviors in 14 (18%). Diagnosis-specific approaches included medical GER therapy in 20 patients (25%), fundoplication plus gastrostomy tube (GT) in 18 (23%), oral supplements in 17 (22%), feeding therapy only in 14 (18%), and GT only in 10 (13%). After 24.6 +/- 3.0 months, relative calorie intake, expressed as intake (kcal/d)/recommended daily allowance (RDA, kcal/d), improved significantly (initial:final = 0.78 +/- 0.36:1.23 +/- 0.27). The z scores increased significantly for both weight (initial:final = -2.80 +/- 1.33:-0.81 +/- 0.69) and height (-3.14 +/- 0.98:-2.00 +/- 0.67). Improved subcutaneous tissue stores were demonstrated by increased thickness of both subscapular skinfolds (change = 71% +/- 26%) and triceps skinfolds (38% +/- 17%). After nutritional intervention, the acute care hospitalization rate, compared with the 2-year period before intervention, decreased from 0.4 +/- 0.18 to 0.15 +/- 0.06 admissions per patient-year and included only 3 admissions (0.02 per patient-year) related to feeding problems.

CONCLUSIONS

In children with developmental disabilities, diagnosis-specific treatment of feeding disorders results in significantly improved energy consumption and nutritional status. These data also indicate that decreased morbidity (reflected by a lower acute care hospitalization rate) may be related, at least in part, to successful management of feeding problems. Our results emphasize the importance of a structured approach to these problems, and we propose a diagnostic and treatment algorithm for children with developmental disabilities and suspected feeding disorders.children, developmental disabilities, fundoplication, gastroesophageal reflux, gastrostomy, hospitalization, nutrition.

Technical aspects of feeding the disabled child

Children with neurological impairment frequently have difficulties in consuming sufficient energy and other nutrients to maintain adequate nutritional status. Under-nutrition is a significant contributory factor to growth failure. Eating may be distressing and time-consuming for the child and carer. Aspiration of feeds is common and may predispose to chronic chest infections. Gastro-oesophageal reflux is also common and may contribute to significant morbidity. This paper discusses some of the issues involved in the nutritional management of neurologically impaired children.