Complications of percutaneous endoscopic gastrostomy in children: a single-center experience

Purpose: Percutaneous endoscopic gastrostomy is the most preferred method for feeding in children with intact gastrointestinal system functions when oral nutrition is insufficient due to neurological, neuromuscular, or oncological diseases. This study aimed to evaluate the indications for percutaneous endoscopic gastrostomy and associated complications in the patients we followed up. Materials and Methods: In this descriptive study, the records of 130 patients who underwent percutaneous endoscopic gastrostomy for nutritional support between January 1st 2013- December 30th 2020 were retrospectively reviewed. Demographic data, indications, complications, and follow-up periods of the patients were examined. Results: Of the patients, 75 were male and 55 were female. The mean age of the patients was 48 months (min 1 month-max 211 months). The evaluation of the patients with percutaneous endoscopic gastrostomy in terms of diagnosis revealed that 95 patients required nutritional support due to neuromotor retardation associated with neurological disease, 19 patients due to central nervous system tumor, and 13 patients due to metabolic disease. Considering complications, the most frequent minor complication was leakage in 11of the 33 patients, while the most frequent major complication was colonic fistulation in 6 of the 9 patients. Two patients required open surgery in the early period due to intra abdominal leak. Conclusion: Although enteral nutrition with a percutaneous endoscopic gastrostomy tube seems to be an appropriate and reliable method to meet the nutritional needs of pediatric patients who have normal digestive system functions but cannot be fed orally due to swallowing disorders, it is necessary to pay attention to its complications like any surgical procedure.

Risk factors of malnutrition in children with severe motor and intellectual disabilities

BACKGROUND

Children with severe motor and intellectual disabilities (SMID) are at a high risk of malnutrition and often require tube feeding to maintain their nutritional status. However, determining their energy requirements is difficult since inadequate dietary intake, severe neurological impairment, respiratory assistance, and cognitive impairment are all factors that affect malnutrition in SMID.

AIM

This study investigated the factors affecting malnutrition and identified problems affecting the nutritional status of children with SMID.

METHODS

Forty-two children with SMID with oral motor dysfunction who were receiving home medical care at one of four hospitals were enrolled. Their nutritional status was assessed using a 3-day dietary record, anthropometric measurements, and laboratory tests. The clinical findings associated with malnutrition were compared, and a body mass index (BMI) z-score less than -2SD was defined as malnutrition. The relationship between BMI z-score and other potential predictors was also investigated.

RESULTS

Thirty-three (79%) children received tube feeding, and 20 (48%) experienced malnutrition. The median age of the malnourished children was older than that of non-malnourished children. Respiratory assistance was significantly correlated with higher BMI z-score, independent of other potential confounders such as nutrition method, muscle tonus, and energy intake. Cholesterol levels were significantly higher in children receiving a standard infant formula beyond 3 years of age than in those who switched to enteral formula before 3 years of age.

CONCLUSIONS

Malnutrition in children with SMID was mainly associated with age or respiratory condition. Energy requirements should be regularly re-evaluated with considering these factors.

Malnutrition is common in children with cerebral palsy in Saudi Arabia - a cross-sectional clinical observational study

BACKGROUND

Cerebral palsy (CP) is considered as the main cause of severe physical impairment and malnutrition in children. This cross-sectional study intended to survey the nutritional status of children cerebral palsy in Riyadh, Saudi Arabia.

METHODS

We examined 74 children (age: 1-10 yrs) with CP, who attended Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh Saudi Arabia. Data on age, general demographics, nutritional status, and dietary intake were collected. A child was considered underweight, wasted, stunted or thin if the standard deviation scores for his/her weight for age, weight for height, height for age and body mass index for age were ≤ -2.0 standard deviation (SD) using WHO growth standards. Multivariable logistic regression identified the factors associated with nutritional indicators.

RESULTS

More than half (56.4%) of the children with cerebral palsy were malnourished as they had z-score below <-2 SD in at least one of the four indicators. Thinness (50%) was the most common form of malnutrition, followed by underweight, stunting, and wasting. Arm anthropometrics gave similar results on the percent number of malnourished children. Factors that were independently associated with malnutrition with an adjusted OR (aOR) were as follow: age ≤ 5 yrs. (aOR: 4.29); presence of cognitive impairment (aOR: 4.13); presence of anemia (aOR: 3.41) and inadequate energy intake (aOR: 4.86) (p, for all trends <0.05).

CONCLUSION

Children with cerebral palsy of the current study have impaired growth and nutritional status as assessed by all four common nutritional status indicators. Further large-scale community-based studies for in-depth evaluation of nutritional status and growth patterns in children with CP are needed.

Resting energy expenditure in children with cerebral palsy: Accuracy of available prediction formulae and development of a population-specific formula

BACKGROUND AND AIMS

Energy requirements are difficult to estimate in children with cerebral palsy (CP). Resting energy expenditure (REE), necessary for personalized nutritional intervention, is most commonly estimated using prediction formulae because the reference method, i.e. indirect calorimetry (IC), is not available in all Nutrition Units. The main aim of the present study was to evaluate the accuracy of the most commonly used REE prediction formulae in children with CP. The secondary aim was to develop a new population-specific formula for the estimation of REE in children with CP.

METHODS

REE was measured by IC in 54 children and adolescents with spastic quadriplegic cerebral palsy (SQCP) and estimated from the five most commonly used prediction formulae, i.e. the World Health Organization (WHO), Harris-Benedict, Schofield weight, Schofield weight & height, and Oxford formulae.

RESULTS

The mean (standard deviation, SD) difference between the estimated and measured REE was 64 (238) kcal/day for the WHO formula, 79 (226) kcal/day for the Schofield weight formula, 79 (223) kcal/day for the Schofield weight and height formula, 55 (226) kcal/day for the Oxford formula, 37 (224) kcal/day for the Harris-Benedict formula and 0 (213) kcal/day for the purposely developed population-specific formula. Owing to the large SD of the bias, none of these formulae can be reliably applied at the individual level to estimate REE.

CONCLUSIONS

The most commonly used REE prediction formulas are inaccurate at both the population and individual level in children with SQCP. A purposely developed population-specific formula, despite being accurate at the population level, does not perform better than the most commonly used REE formulae at the individual level.

Neuromuscular complications of immune checkpoint inhibitor therapy

Immune checkpoint inhibitor (ICPI) therapy unleashes the body's natural immune system to fight cancer. ICPIs improve overall cancer survival, however, the unbridling of the immune system may induce a variety of immune-related adverse events. Neuromuscular immune complications are rare but they can be severe. Myasthenia gravis and inflammatory neuropathy are the most common neuromuscular adverse events but a variety of others including inflammatory myopathy are reported. The pathophysiologic mechanism of these autoimmune disorders may differ from that of non-ICPI-related immune diseases. Accordingly, while the optimal treatment for ICPI-related neuromuscular disorders generally follows a traditional paradigm, there are important novel considerations in selecting appropriate immunosuppressive therapy. This review presents 2 new cases, a summary of neuromuscular ICPI complications, and an approach to the diagnosis and treatment of these disorders. Muscle Nerve, 2018.

Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention

Children with severe impairment of the central nervous system (CNS) experience gastrointestinal (GI) symptoms at a high rate and severity, including retching, vomiting, GI tract pain, and feeding intolerance. Commonly recognized sources of symptoms include constipation and gastroesophageal reflux disease. There is growing awareness of sources due to the impaired nervous system, including visceral hyperalgesia due to sensitization of sensory neurons in the enteric nervous system and central neuropathic pain due to alterations in the thalamus. Challenging the management of these symptoms is the lack of tests to confirm alterations in the nervous system as a cause of symptom generation, requiring empirical trials directed at such sources. It is also common to have multiple reasons for the observed symptoms, further challenging management. Recurrent emesis and GI tract pain can often be improved, though in some not completely eliminated. In some, this can progress to intractable feeding intolerance. This comprehensive review provides an evidence-based approach to care, a framework for recurrent symptoms, and language strategies when symptoms remain intractable to available interventions. This summary is intended to balance optimal management with a sensitive palliative care approach to persistent GI symptoms in children with severe impairment of the CNS.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.