Gastrointestinal and nutritional problems in neurologically impaired children

Definition, investigation and management of gastrointestinal dystonia in children and young people with neurodisability

BACKGROUND

Children and young people with severe neurodisabling conditions (CYPSND)experience severe functional gastrointestinal symptoms and dependence on artificial nutrition. 'Gastrointestinal dystonia' (GID) has been applied by clinicians when symptoms become debilitating and potentially life-limiting. Evidence is lacking regarding the definition and appropriate management of GID.

METHODS

We therefore assembled a RAND appropriateness panel. We performed a systematic review, created an online survey and distributed this to a panel of 27 experts from five stakeholder groups from 13 UK specialist centres across the British Isles (gastroenterology, neurology/neurodisability, surgery, palliative care and allied health professionals). A Disagreement Index ≥1 indicated disagreement.

FINDINGS

The panel rated the appropriateness of 250 statements covering the following in GID: definition, clinical evaluation, nutritional assessment/feeding strategies, investigations, medications and prescribing, surgical interventions, safeguarding, palliative care and ethics. Agreement was reached except in selected statements regarding uncommon diagnostic features. There was uncertainty in specific clinical scenarios regarding: investigation, the use of blenderised diet, certain pharmacological agents and surgical interventions. The only intervention deemed inappropriate was antireflux surgery in the context of GID and gastrointestinal dysmotility without reflux disease. The remaining statements (198) were considered appropriate.

INTERPRETATION

We present a comprehensive review, agreement on the definition of GID and recommendations on management pathways agreed by a selected panel of multidisciplinary experts. Clear diagnostic criteria will enable important epidemiological work to record outcomes for this complex patient group. Identifying the associated morbidity, burden of care and mortality will help advocate for appropriate health resources and support to carers and families.

A pre-operative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery

PURPOSE

Pediatric cerebral palsy patients carry frequent medical comorbidities and disproportionately consume hospital resources after neurosurgical procedures. We implemented an institutional pre-operative gastrointestinal (GI) optimization protocol to improve outcomes and decrease resource utilization.

METHODS

All 323 intrathecal baclofen surgeries from 2000 to 2023 were categorized relative to protocol implementation on July 1, 2017. Outcomes and resource utilization were compared.

RESULTS

The protocol change resulted in significantly fewer hospital readmissions (p = 0.001) for constipation, eliminating them and GI-related emergency visits. There was a reduction of 27 hospital days for constipation-related readmission (median 1 day per patient, IQR 1, 2 days). No differences were reported between the experimental groups including demographics or GI comorbidities. Post-operative complications within 30 days were comparable between groups regarding urinary tract infections, surgical-site infections, and spinal fluid leak. There were no differences in post-operative length of stay between groups.

CONCLUSION

A GI optimization protocol can eliminate a frequent source of hospital readmissions and GI-related emergency department visits after baclofen pump surgery, even accounting for baseline GI comorbidities. Preventing readmissions and emergency visits translates to lower hospital resource utilization and improves quality of care. Future efforts are warranted to improve outcomes and care efficiency for our most complex and resource-intensive patients.

A single center experience on clinical outcome of fundoplication in pediatric patients: a retrospective cohort study

Purpose

The study aimed to evaluate the characteristics and operative-related factors in children who underwent fundoplication, analyze surgical outcomes categorized by disease entity and surgical indication, and identify prognostic factors for reoperation risk.

Methods

A total of 109 pediatric patients who underwent fundoplication between 2008 and 2022 were retrospectively analyzed. Patients were grouped by disease entity and surgical indication. Underlying diseases, comorbidities, sex, gestational age, birth weight, preoperative symptoms, and operation-related factors were examined. Outcomes were classified as short-term and long-term adverse events. We investigated differences in clinical outcomes according to disease entity and surgical indication. Then we statistically identified preoperative predictors for the risk of reoperation.

Results

The most common disease entity was neurological impairment (n = 92). Pulmonary comorbidity (42.2%) and aspiration/regurgitation (87.2%) were the most common. Most surgeries were performed laparoscopically (86.2%). There were 12 short-term and 25 long-term adverse events, with long-term events occurred more frequently in the neurological impairment (NIP) group compared to the non-NIP group (P = 0.04). None of the factors showed a significant relationship with the risk of reoperation.

Conclusion

Neurologically impaired children were more likely to experience long-term adverse events post-fundoplication. However, no significant predictors for reoperation risk were identified.

Use of a specialized peptide-based enteral formula containing medium-chain triglycerides for enteral tube feeding in children with cerebral palsy and previous tube feeding intolerance on standard enteral formula: a prospective observational TolerUP study

Objective

Use of peptide-based formulas supplemented with medium chain triglycerides (MCTs) is considered a beneficial strategy to decrease the tube-feeding associated gastrointestinal tolerance. In children with cerebral palsy (CP), overall effects of enteral tube feeding as well as the utility of peptide-based specialized enteral formulas in those with gastrointestinal intolerance have not been extensively studied. This study aimed to evaluate the utility of enteral tube feeding via specialized peptide-based formula containing MCTs in children with CP in terms of gastrointestinal intolerance, anthropometrics, defecation characteristics and parental satisfaction with enteral formula.

Methods

Children with CP who received enteral tube feeding via specialized peptide-based formula containing MCTs were included in this prospective observational study. Anthropometrics (z scores for weight for age [WFA], weight for height [WFH], triceps skinfold thickness [TSFT] and mid-upper arm circumference [MUAC]), gastrointestinal intolerance symptoms, defecation frequency and stool patterns and formula satisfaction were recorded at baseline and during 6-month follow up.

Results

A total of 96 children with CP (mean ± SD age: 5.6 ± 3.2 years, 56.3% were boys) were included. Significant improvements were noted in MUAC, TSFT and WFH z scores at the 6th month visit. The rate of "severe symptoms" and the likelihood of Type-1/Type-2 (constipation) stool pattern were significantly decreased. Majority of parents were satisfied with the study formula.

Conclusion

Our findings revealed favorable efficacy and safety of using a specialized peptide-based formula containing MCT in provision of enteral tube feeding among children with CP in terms of improved anthropometrics, amelioration of gastrointestinal intolerance symptoms and normalization of bowel movements along with a high parental satisfaction.

Exploring Dietitians' Experience of Blended Tube Feed in Paediatric Inpatient Settings: National Cross-Sectional Survey, United Kingdom

BACKGROUND

Enteral tube feeding is used for children who are unable to meet their nutritional requirements orally. Gastrointestinal symptoms are some complications that can occur in enteral tube-fed patients. Blended tube feeds (BTFs) for children who are gastrotomy tube-fed have significantly increased in the last decade. BTF refers to homemade food that has been liquidised for enteral tube feeds. An increasing amount of evidence suggests that children on BTF have improved feed tolerance. It is unknown whether children admitted to a hospital established on a BTF can continue a BTF due to the potential barriers such as catering processes, staffing hours (limited to syringe bolus feeding) and food safety concerns. This national cross-sectional survey aimed to explore the use of BTF in a paediatric hospital setting.

METHODS

This was a prospective, cross-sectional, practice-based survey of registered paediatric dietitians who work in an inpatient care setting to explore the use of BTF. The final survey consisted of 13 questions and took dietitians approximately 15 min to complete. The questions focused on the dietitian's experience, knowledge and confidence in children on a BTF.

RESULTS

Across the United Kingdom, 51 hospitals completed the survey. Of these, 16 of 19 were specialist children's hospitals (79% response rate) and 35 of 89 were general paediatric hospitals (39% response rate). All responders were paediatric dietitians. 49 of 51 (96%) dietitians knew of the British Dietetic Association (BDA) Practice Toolkit for Blended diets. Dietitians were asked to estimate on average per month how many children were admitted on a BTF; 41% (21 of 51) of dietitians reported that on average there are one to five children admitted on a BTF. There was no significant difference in the number of children admitted on a BTF between a specialist and a general children's hospital (χ2 statistic = 4.96, p value < 0.08). The number of dietitians who had clinical guidelines to support children admitted on a BTF was 49% (25 of 51). Specialist children's hospitals were more likely to have a clinical guideline compared with a general hospital (χ2 statistic = 6.348, p value = 0.01). However, only 18 of 51 (35%) dietitians reported being confident or very confident to review a child on a BTF. The most common perceived benefit was that parents/carers could incorporate family foods into their child's diet. 26% reported that a varied diet was beneficial in relation to the gut microbiome. If a BTF was contraindicated for children admitted to a hospital (immunocompromised, post-pyloric feeding or intensive care), 49 of 51 (96%) dietitians reported they would use an enteral formula with food-derived ingredients (Compleat paediatric-Nestle Health Science) as an alternative to a BTF.

CONCLUSION

BTF continues to grow in popularity. Our survey reported that children on BTF are frequently admitted to the hospital. There is growing evidence to support BTF in relation to family psychosocial health and feed tolerance. Dietitians must keep abreast of this fast-evolving area practice to ensure that they are the experts in BTF. When a BTF is contraindicated, an enteral formula with food-derived ingredients is a suitable alternative. Issues such as microbial contamination, nutritional composition, and adequacy of diluted BTF need further exploration.

Different care mode alter composition and function of gut microbiota in cerebral palsy children

Introduction

Specialized care is essential for the recovery of children with cerebral palsy (CP). This study investigates how different care modes impact the gut microbiota.

Methods

Fecal samples from 32 children were collected, among whom those cared for by family (n = 21) were selected as the observation group, and those cared for by children's welfare institutions (n = 11) were selected as the control group (registration number of LGFYYXLL-024). The gut microbiota profiles were analyzed.

Results

There was no significant difference in the α-diversity of the gut microbiota and the abundance at the phylum level. However, at the genus level, the observation group showed a significant increase in the abundance of butyrate-producing bacteria Bacteroides and Lachnospiracea incertae sedis (P < 0.05), and a significant decrease in the abundance of opportunistic pathogens Prevotella, Clostridium cluster IV, Oscillibacter, and Fusobacterium (P < 0.05). Additionally, lipid metabolism, carbohydrate metabolism, transcription, cellular processes and signaling, and membrane transport were significantly upregulated in the observation group. Lipid metabolism was positively correlated with Bacteroides and Lachnospiracea incertae sedis, indicating a positive impact of the family-centered care mode on bacterial metabolism processes.

Discussion

This study highlights that the family-centered care mode had a positive impact on the composition and function of the gut microbiota. The study provides valuable insights into the relationship between care mode and gut microbiota, which can inspire the development of interventions for cerebral palsy.

The impact of low-energy, partially hydrolysed enteral formula on gastrointestinal symptoms and weight in children with neurological impairment: a multicentre retrospective study

BACKGROUND

Neurological impairment (NI) relates to disorders of the central nervous system. The specific aetiology of NI varies but includes genetic, congenital abnormalities or brain injury. In children with severe NI, feeding impairments can lead to undernutrition, and some children require a feeding tube. Although tube feeding improves overall nutritional status, it has also been associated with excess body fat. Commercially available enteral formulas that are low in energy, hydrolysed and nutritionally adequate for protein and micronutrients are available to mitigate gastrointestinal symptoms and obesity.

METHODS

This is a retrospective multicentre study of children who attended NI clinics between January 2022 and July 2023. Data were collected before and 1 month after receiving a low-energy, partially hydrolysed enteral formula (0.6 kcal/mL) on demographic data (age, sex, ethnicity and NI diagnosis), anthropometric measurements (weight, height, weight-for-age Z-score, height-for-age Z-score, body mass index [BMI] Z-score) and feed regimen (feed volume, total fluids and type of formula/supplements).

RESULTS

Dietitians collected data on 28 children, the median age was 7 years (interquartile range [IQR] 3, 8). The most frequently recorded NI was cerebral palsy, in 13 of 28 children (48%). Before the formula switch, the most frequently reported gastrointestinal symptom was constipation, in 13 of 28 children. Within 1 month of switching to a low-energy, hydrolysed formula, 10 of the 13 (77%) children reported an improvement in constipation. Before the formula switch, all 28 children were experiencing excessive weight gain. After the formula was switched to low-energy, hydrolysed formula, dietitians reported that 20 of the 28 (76%) children's weight either stabilised or reduced after 1 month. There was no statistically significant difference in weight-for-age Z-score or BMI Z-scores postswitch of formula (p-value 0.1 and 0.09, respectively). Fibre intake increased significantly from 3.3 to 8.1 g/day (p-value < 0.01) after formula switch. The number of children whose feed regimens were simplified after switching to a low-energy, partially hydrolysed formula was 24 of 28 (91%).

CONCLUSIONS

Children with an NI who have gastrointestinal symptoms may benefit from a low-energy, hydrolysed enteral formula to maximise feed tolerance and promote healthy weight gain. In addition, changing to a low-energy, hydrolysed formula may simplify feed regimens by eliminating the need for additional electrolytes, multivitamins and fluid boluses. Healthcare professionals should be knowledgeable about the effectiveness and availability of a low-energy, hydrolysed formula.

Modification of the Paediatric Gastro-oesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) for children with cerebral palsy: a preliminary study

OBJECTIVE

Gastro-oesophageal reflux disease (GORD) is a common condition affecting children, characterised by the passage of gastric contents into the oesophagus causing pain, vomiting and regurgitation. Children with neurodisability (such as cerebral palsy; CP) are predisposed to more severe GORD due to coexisting gut dysmotility and exclusive/supplementary liquid diet; however, there are no existing tools or outcome measures to assess the severity of GORD in this patient group. For children without CP, the 'Paediatric Gastro-oesophageal Symptom and Quality of Life Questionnaire' (PGSQ) assesses symptoms and response to treatment, but the questions are not suitable for children with significant cognitive impairment. We aimed to adapt the existing PGSQ assessment tool to enable use in evaluating children with CP and GORD.

PATIENTS/INTERVENTIONS

Cognitive interviews were conducted by the research team with six parents/carers of children (aged 3-15) with CP (Gross Motor Function Classification System level V) who have current or past symptoms of reflux. They were asked to interpret the questionnaire using a 'think-aloud technique,' and offer suggestions on alterations to questions. Reasons for changing questions included confusing/difficult to understand questions, differing interpretations of questions and response choices not applying to the patient group.

RESULTS

The PGSQ was modified iteratively following each interview. Overall, parents/carers reported that it was acceptable to recall information over the past 7 days. In the final version, it was felt the questions were relevant, useful and related to symptoms that they observed. It was easy to comprehend with no uncomfortable questions. Suggestions for future work included a section specifically focusing on the school day answered by school staff and home life answered by carers who assist them in the home.

CONCLUSIONS

We have adapted the PGSQ to improve relevance and acceptability for families/carers of children with symptoms of GORD and neurodisability. Further work is needed to validate the questionnaire for this patient group.

Intake levels and main sources of nutrients for Japanese children with motor or intellectual disabilities

Proper nutritional management is important for the growth and development of children with motor or intellectual disabilities; however, few studies have investigated the nutrient intake of children with disabilities. This study aimed to investigate the nutrient intake and food groups that are the main sources of nutrients for children with disabilities. This cross-sectional observational study included twenty-five children (mean age, 11⋅8 years) from five hospitals in Japan. Using a 3-d weighed dietary record, we estimated the daily nutrient intake and food and beverage sources that contributed to nutrient intake. The mean values of calcium, magnesium, iron, vitamin A, thiamine, riboflavin, and vitamin C intake were below the recommended dietary allowance, and those of dietary fiber and potassium were below the levels recommended by the Tentative Dietary Goal for Preventing Lifestyle-related Diseases (DG). In contrast, the mean intake values of fat, saturated fatty acids, and sodium were above the DG levels. Dairy products, meat, vegetables, and cereals were found to be the major contributors of nutrients. Increased intake of vegetables may help alleviate insufficient micronutrient intake in children with disabilities.

Mediterranean diet is associated with better gastrointestinal health and quality of life, and less nutrient deficiency in children/adolescents with disabilities

Background

Children and adolescents with disabilities face various nutritional problems. This study aimed to examine dietary characteristics, nutritional status and problems, gastrointestinal health, and quality of life in children and adolescents with disabilities.

Methods

This study included 5-18 years old children and adolescents (n = 1,991) with disabilities. We used the Mediterranean Diet Quality Index (KIDMED), the Gastrointestinal Symptom Rating Scale (GSRS), and the Pediatric Quality of Life Inventory (PedsQL) to assess diet characteristics, gastrointestinal problems, and life quality. We collected retrospective 24-h food record to assess energy and nutrient intakes.

Results

The rate of stunting in children with disabilities varies between 16.5% and 19.8%. When comparing disability types, more children with physical disabilities were underweight (8.8% vs. 6.7%) and stunted (19.8% vs. 16.5%), while more children with intellectual disabilities were tall (7.9% vs. 5.5%) and overweight/obese (21.1 vs. 17.2%; p < 0.05). Wasting (9.3%) and overweight/obesity (23.8%) were more common in children with disabilities aged 5-7 years (p < 0.001). Eating problems such as loss of appetite, food refusal, food neophobia, and food selectivity were more common in children aged 5-7 years, and problems with fast eating and overeating were more common in adolescents aged 13-18 years (p < 0.05). Among children and adolescents with disabilities, the nutrients with inadequate intakes were vitamin E, vitamin B1, folate, potassium, calcium, and iron, while the nutrients with intakes above the requirements were proteins, carbohydrates, vitamins A, B2, B6, B12, and C, phosphorus, zinc, and sodium. Participants with good Mediterranean diet quality had higher energy and nutrient intakes and higher percentages of meeting nutrient requirements (p < 0.05). KIDMED scores were negatively correlated with GSRS total (r = -0.14, p < 0.001) and subcomponent scores (abdominal pain, diarrhea, reflux, indigestion, and constipation; p < 0.05), and significantly and positively correlated with PedsQL total (r = 0.12, p < 0.001). A one-unit increase in the GSRS score resulted in a 14.4 times decrease in the PedsQL score, and a one-unit increase in the KIDMED score resulted in a 10.8 times increase in the PedsQL score (p = 0.001).

Conclusion

Overweight/obesity, stunting/wasting, nutritional problems, and deficiencies are common among disabled children and adolescents. Mediterranean diet is associated with a better quality of life, and gastrointestinal health in children with disabilities.

Exploring gastrointestinal health in MECP2 duplication syndrome

BACKGROUND

MECP2 duplication syndrome (MDS) is a rare neurogenetic syndrome caused by duplications of MECP2 at the Xq28 region. Although constipation and gastrointestinal reflux are reported in MDS, a comprehensive characterization of gastrointestinal health has not been fully explored.

METHODS

We conducted a parent survey to explore the characteristics of gastrointestinal health in individuals with MDS using a secure online registry and compared differences in gastrointestinal symptoms between individuals with MDS and those with Rett syndrome (RTT).

KEY RESULTS

One hundred six surveys were analyzed. Symptoms commonly associated with constipation occurred in 72% to 89% of MDS individuals. Eleven percent of MDS individuals underwent surgery for complications associated with constipation. We observed a bimodal distribution for gastroesophageal reflux disease (GERD) and gastrostomy feeding, with higher prevalence in 0-3 and >12-year-old MDS individuals. Constipation and GERD were significantly more common, and gas bloating was significantly less common in MDS than in RTT. Biliary tract disease requiring surgery was an unrecognized problem in 5% of MDS individuals. We determined that gastrointestinal problems in MDS individuals contribute to caretaker burden.

CONCLUSION AND INFERENCES

Our study is the first in-depth investigation that characterizes gastrointestinal health in MDS and enumerates differences in gastrointestinal symptoms between MDS and RTT. Strategies to reduce gastrointestinal symptoms will alleviate caregiver burden in MDS. Further studies are needed to examine the mechanisms that cause gastrointestinal problems in MDS.

Gut dysmotility in children with neurological impairment: the nutritional management

Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.

The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children

This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.

Growth Velocity and Nutritional Status in Children Exposed to Zika Virus during Pregnancy from Amazonas Cohort, Brazil

The high incidence of Zika virus (ZIKV) infection in the period of 2015–2016 in Brazil may have affected linear height growth velocity (GV) in children exposed in utero to ZIKV. This study describes the growth velocity and nutritional status based on the World Organization (WHO) standards of children exposed to ZIKV during pregnancy and followed up in a tertiary unit, a reference for tropical and infectious diseases in the Amazon. Seventy-one children born between March 2016 and June 2018 were monitored for anthropometric indices: z-score for body mass index (BMI/A); weight (W/A); height (H/A) and head circumference (HC/A); and growth velocity. The mean age at the last assessment was 21.1 months (SD ± 8.93). Four children had congenital microcephaly and severe neurological impairment. The other 67 were non-microcephalic children (60 normocephalic and 7 macrocephalic); of these; 24.2% (16 children) had neurological alterations, and 28.8% (19 children) had altered neuropsychomotor development. Seventeen (24.2%) children had inadequate GV (low growth velocity). The frequencies of low growth among microcephalic and non-microcephalic patients are 25% (1 of 4 children) and 23.9% (16 of 67 children); respectively. Most children had normal BMI/A values during follow-up. Microcephalic patients showed low H/A and HC/A throughout the follow-up, with a significant reduction in the HC/A z-score. Non-microcephalic individuals are within the regular ranges for H/A; HC/A; and W/A, except for the H/A score for boys. This study showed low growth velocity in children with and without microcephaly, highlighting the need for continuous evaluation of all children born to mothers exposed to ZIKV during pregnancy.

Feasibility of Laparoscopic Fundoplication Without Removing the Preceding Gastrostomy in Severely Neurologically Impaired Patients: A Multicenter Evaluation of the Traction Technique

Purpose: Severely neurologically impaired patients sometimes require anti-reflux surgery with preceding gastrostomy. We apply a traction technique for laparoscopic fundoplication (LF) without gastrostomy takedown (GTD) in such cases. We conducted a multicenter review to assess the feasibility of our approach. Materials and Methods: In brief, the traction technique involves left-lateral-traction of the stomach body, right-lateral-traction of the round ligament of the liver, and elevation of the left liver lobe to create a sufficient field for manipulating the forceps. Patients who underwent LF with Nissen's procedures in 2010-2022 were retrospectively reviewed. Data were analyzed by a one-way analysis of variance. Results: The operative approaches included the traction technique (n = 16; Group 1), GTD and reconstruction (n = 5; Group 2), and LF followed by gastrostomy (n = 92; Group 3). In comparison with Group 1, significant differences were only found in pneumoperitoneum time (Group 1 versus Group 2 versus Group 3: 174.4 minutes versus 250.4 minutes versus 179.5 minutes; P = .0179). Operating time (222.7 minutes versus 303.0 minutes versus 239.7 minutes; P = .0743), duration to full-strength enteral nutrition (10.4 days versus 17.2 days versus 11.0 days; P = .0806), and length of hospital stay (17.2 days versus 31.0 days versus 18.5 days; P = .3247) were equivalent. No re-fundoplication was required in Group 1. Conclusion: The traction technique secures the operative quality and outcome of LF without GTD.

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

Nutritional status and prevalence of dysphagia in cerebral palsy: usefulness of the Eating and Drinking Ability Classification System scale and correlation with the degree of motor impairment according to the Gross Motor Function Classification System

INTRODUCTION AND OBJECTIVES

Digestive disorders are one of the most common comorbidities among children with cerebral palsy (CP). The aim of this study is to examine the nutritional status of patients with CP, the prevalence of dysphagia by degree of motor impairment, and the impact of digestive disorders on quality of life.

MATERIAL AND METHODS

We conducted a descriptive, cross-sectional, open-label study of out-patients with CP from a tertiary hospital in the Region of Madrid using a structured interview, classifying dysphagia using the Eating and Drinking Ability Classification System (EDACS). We gathered demographical and anthropometric data, and analysed the correlation between severity of dysphagia and functional status as measured with the Gross Motor Function Classification System (GMFCS).

RESULTS

Our sample included 44 patients (65.9% boys), with a mean (standard deviation) age of 9.34 (5) years and a mean BMI of 18.5 (4.9). Forty-three percent presented safety and efficiency limitations (EDACS level > II). Safety and efficiency limitations were associated with more extensive motor involvement (60% had tetraparesis), more varied clinical manifestations (87% had mixed forms) and poorer functional capacity (100% on GMFCS V). The impact on nutritional status increased with higher EDACS and GMFCS scores.

CONCLUSIONS

This is the first study into the usefulness of the EDACS scale in a representative sample of Spanish children and adolescents with CP. Our findings underscore the importance of screening for dysphagia in these patients, regardless of the level of motor impairment, and the need for early treatment to prevent the potential consequences: malnutrition (impaired growth, micronutrient deficiencies, osteopaenia, etc.), microaspiration, or recurrent infections that may worsen patients' neurological status.

Evaluation of Dysphagia and Inhalation Risk in Neurologically Impaired Children Using Esophageal High-Resolution Manometry with Swallowing Analysis

BACKGROUND

Dysphagia in neurologically impaired children is associated with feeding difficulties, malnutrition and aspiration pneumonia. Esophageal high-resolution manometry (HRM) has been used in the diagnosis of motility disorders affecting the swallowing process. The aim of this study was to analyze swallowing functions in NI children by using HRM in order to establish swallow parameters identifying inhalation risk.

METHODS

Twenty-five NI children with cerebral palsy were submitted to esophageal HRM with UES analysis, comparing the results with non-NI children. The following parameters were evaluated: maximum pressure and duration of contraction of the velopharynx (VP) and tongue base (TB), and maximal, minimal, resting pressure and relaxation duration of the upper esophageal sphincter (UES).

RESULTS

pVP max, pTB max, pUES max and resting pressure were lower, while p UES minimal was higher and relaxation duration was shorter in NI children vs. the control group. Predictive values of inhalation risk were evaluated.

CONCLUSIONS

This study evaluates inhalation risk in NI children using HRM to study UES function. Our results confirm the alterations described in NI children: insufficient contraction and clearing force for bolus transmission through the pharynx and incomplete UES relaxation can predispose to pharyngeal residues and inhalation independently of swallowing because of lower values of UES resting.

Decreasing Time to Full Enteral Feeds in Hospitalized Children With Medical Complexity Experiencing Feeding Intolerance

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) with gastrostomy and jejunostomy tubes are commonly hospitalized with feeding intolerance, or the inability to achieve target enteral intake combined with symptoms consistent with gastrointestinal dysfunction. Challenges resuming feeds may prolong length of stay (LOS). Our objective was to decrease median time to reach goal feeds from 3.5 days to 2.5 days in hospitalized CMC with feeding intolerance.

METHODS

A multidisciplinary team conducted this single-center quality improvement project. Key drivers included: standardized approach to feeding intolerance, parental buy-in and shared understanding of parental goals, timely formula delivery, and provider knowledge. Plan-do-study-act cycles included development of a feeding algorithm, provider education, near-real-time reminders and feedback. A run chart tracked the effect of interventions on median time to goal enteral feeds and median LOS.

RESULTS

There were 225 patient encounters. The most common cooccurring diagnoses were viral gastroenteritis, upper respiratory infections, and urinary tract infections. Median time to goal enteral feeds for CMC fed via gastrostomy or gastrojejunostomy tubes decreased from 3.5 days to 2.5 days within 6 months and was sustained for 1 year. This change coincided with implementation of a feeding intolerance management algorithm and provider education. There was no change in LOS.

CONCLUSIONS

Implementation of a standardized feeding intolerance algorithm for hospitalized CMC was associated with decreasing time to goal enteral feeds. Future work will include incorporating the algorithm into electronic health record order sets and spread of the algorithm to other services who care for CMC.

Vomiting and Gastric Motility in Early Brain Damaged Children With Congenital Zika Syndrome

OBJECTIVES

This study investigated the occurrence of vomiting and gastric dysmotility in dysphagic children with congenital Zika syndrome (CZS) and assessed possible associations of these findings with the severity of dysphagia and the presence of tube feeding.

METHODS

Forty-six children with CZS were assessed for dysphagia, and the occurrence of vomiting, dietary volume tolerance <15 mL/kg, and feeding time per meal >30 minutes were evaluated. Gastric antrum ultrasonography was used to detect the frequency of contractions and measure antral areas (at fasting and 15 minutes postprandial), from which the gastric emptying rate (GER) was calculated. Antral ultrasonography findings were compared with those of ten healthy controls. Vomiting and gastric motility were compared between CZS patients according to the severity of dysphagia and the requirement for tube feeding.

RESULTS

Overall, 76% (35/46) of children with CZS had moderate-to-severe dysphagia (MSD), among whom 60% (21/35) were tube fed [MSD tube fed (MSDTF)]. Vomiting occurred in 54% (25/46) of children, whereas dietary volume intolerance and prolonged feeding time were observed in 59% (27/46) and 37% (17/46), respectively, most frequently in MSDTF patients. On ultrasound, 61% (28/46) of children with CZS had no antral contractions, whereas 90% (9/10) of controls did. Compared to healthy controls, GER was eight-fold lower in children with CZS and 60-fold lower in MSDTF children.

CONCLUSIONS

In dysphagic children with CZS, vomiting, volume intolerance, and prolonged feeding time were frequent and possibly associated with impaired antral contraction and delayed gastric emptying, especially in cases of severe dysphagia and tube feeding.

Useful traction technique for laparoscopic fundoplication without removing proceeding gastrostomy in a neurologically impaired patient with a body deformity

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.

LUNCH-Lung Ultrasound for early detection of silent and apparent aspiratioN in infants and young CHildren with cerebral palsy and other developmental disabilities: study protocol of a randomized controlled trial

Background

Children with neurological impairment may have dysphagia and/or gastro-esophageal reflux disease (GERD), which predispose to complications affecting the airways, increasing risk for aspiration-induced acute and chronic lung disease, or secondarily malnutrition, further neurodevelopmental disturbances, stressful interactions with their caregivers and chronic pain. Only multidisciplinary clinical feeding evaluation and empirical trials are applied to provide support to the management of feeding difficulties related to dysphagia or GERD, but no standardized feeding or behavioral measure exists at any age to assess aspiration risk and support the indication to perform a videofluoroscopic swallowing study (VFSS) or a fibre-optic endoscopic examination of swallowing (FEES), in particular in newborns and infants with neurological impairments. Lung ultrasound (LUS) has been proposed as a non-invasive, radiation-free tool for the diagnosis of pulmonary conditions in infants, with high sensitivity and specificity.

Methods

A RCT will be conducted in infants aged between 0 and 6 years having, or being at risk for, cerebral palsy, or other neurodevelopmental disease that determines abnormal muscular tone or motor developmental delay assessed by a quantitative scale for infants or if there is the suspicion of GERD or dysphagia based on clinical symptoms. Infants will be allocated in one of 2 groups: 1) LUS-monitored management (LUS-m); 2) Standard care management (SC-m) and after baseline assessment (T0), both groups will undergo an experimental 6-months follow-up. In the first 3 months, infants will be evaluated a minimum of 1 time per month, in-hospital, for a total of 3 LUS-monitored meal evaluations. Primary and secondary endpoint measures will be collected at 3 and 6 months.

Discussion

This paper describes the study protocol consisting of a RCT with two main objectives: (1) to evaluate the benefits of the use of LUS for monitoring silent and apparent aspiration in the management of dysphagia and its impact on pulmonary illness and growth and (2) to investigate the impact of the LUS management on blood sample and bone metabolism, pain and interaction with caregivers.

Trial registration

Trial registration date 02/05/2020; ClinicalTrials.gov Identifier: NCT04253951.

Use of home parenteral nutrition in severely neurologically impaired children

OBJECTIVE

To review the outcome of children with severe neurological impairment (NI) and intestinal failure (IF) referred to our specialist multidisciplinary IF rehabilitation service and to discuss implications.

DESIGN

Case report series, descriptive analysis.

SETTING

IF rehabilitation programme at a tertiary children's hospital in the UK.

PATIENTS

Children with severe NI referred to our IF rehabilitation programme from 2009 to 2019.

MAIN OUTCOME MEASURES

Demographic and social data, diagnosis, clinical condition, use of home parenteral nutrition (HPN), complications, ethics review outcome and advance care plans.

RESULTS

Six patients with severe NI were referred to our IF rehabilitation service. Consent for publication was obtained from five families. After thorough medical review and clinical ethics committee assessment, three children started HPN, one had intravenous fluids in addition to enteral feed as tolerated and one intravenous fluids only. The HPN children survived 3-7.08 years (median 4.42 years) on treatment. Objective gastrointestinal signs, for example, bleeding improved without excessive HPN-related complications. Symptomatic improvement was less clear. Analgesia was reduced in three of the five children. All cases had detailed symptom management and advance care plans regularly updated.

CONCLUSIONS

HPN can play a role in relieving gastrointestinal signs/symptoms in children with severe NI and IF. HPN can be conceptualised as part of good palliative care if judged to be in the child's best interests. However, given its risks and that HPN has the potential to become inappropriately life-sustaining, a thorough ethics review and evaluation should be performed before it is initiated, withheld or withdrawn in children with severe NI.

Embracing the Nutritional Assessment in Cerebral Palsy: A Toolkit for Healthcare Professionals for Daily Practice

Background: Nutritional status assessment (NSA) can be challenging in children with cerebral palsy (CP). There are high omission rates in national surveillance reports of weight and height information. Alternative methods are used to assess nutritional status that may be unknown to the healthcare professionals (HCP) who report these children. Caregivers experience challenges when dealing with feeding problems (FP) common in CP. Our aim was to assess the difficulties in NSA which are causing this underreport and to create solutions for registers and caregivers. Methods: An online questionnaire was created for registers. Three meetings with HCP and caregivers were held to discuss problems and solutions regarding NSA and intervention. Results: HCP mentioned difficulty in NSA due to a lack of time, collaboration with others, equipment, and childrens’ motor impairment. Caregivers experienced difficulty in preparing nutritious meals with adapted textures. The creation of educational tools and other strategies were suggested. A toolkit for HCP was created with the weight and height assessment methods described and other for caregivers to deal with common FP. Conclusions: There are several difficulties experienced by HCP that might be overcome with educational tools, such as a toolkit. This will facilitate nutritional assessment and intervention and hopefully reduce underreporting.

Nutritional Management of Children With Neurological Impairment in China: Current Status and Future Directions

The aim of this study is to assess the awareness of Chinese physicians on gastrointestinal and nutritional management of children with neurological impairment (NI) and to assess the practical application of the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines on the management of nutritional and gastrointestinal problems in children with NI in Asian countries, particularly in several major medical centers in China.

METHODS

A web-based questionnaire was distributed between November 2020 and January 2021 among Chinese healthcare professionals involved in the clinical management of children with NI. Fifteen questions covering the most relevant aspects of nutritional management and gastrointestinal issues of children with NI were surveyed. A descriptive analysis of responses was performed.

RESULTS

A total of 577 healthcare professionals from over 28 provinces in China answered the questionnaire. Anthropometrics were the most used parameters (n = 539) to assess nutritional status. Most respondents (n = 455) indicated weight faltering and/or failure to thrive as definition of undernutrition. Direct observation of meals was considered the recommended method for diagnosing oropharyngeal dysfunction by 542 professionals. Fundoplication was indicated at the time of gastrostomy placement in patients with uncontrolled gastroesophageal reflux disease by 437 respondents.

CONCLUSIONS

The clinical practice of Chinese healthcare professionals does not completely match the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines, probably due to the medical system and the economic, social, and cultural differences. Further studies are needed to improve clinical practice and knowledge. Multidisciplinary approach is crucial to optimize the overall medical care and quality of life for children with NI.

Experiences before and after nasogastric and gastrostomy tube insertion with emphasis on mealtimes: a case study of an adolescent with cerebral palsy

Purpose: Adolescents with cerebral palsy may need a feeding tube due to feeding challenges, since nutritional intake and mealtimes may be negatively affected. The purpose of the study was to describe and better understand how one adolescent with cerebral palsy and her parents experienced mealtimes before and after a nasogastric and gastrostomy tube insertion and how the use of these feeding tubes was experienced in daily life.Methods: Individual interviews were performed with one adolescent and each of her parents. In total, six interviews were conducted on two separate occasions. The qualitative approach known as Interpretive Description was used during the analysis.Results: Four thematic patterns were identified within the data: (i) struggling with nutritional intake, (ii) the paradox of using an aid, (iii) being different, and (iv) challenges of public mealtimes.Conclusions: The results showed that four themes influenced daily mealtimes in adolescents with cerebral palsy and a gastrostomy tube. Nutritional intake and mealtimes may be difficult, which is why using a gastrostomy tube can be a relief. However, the gastrostomy tube can also pose a challenge and a paradox. Time of change and acceptance seems necessary in order to meet these challenges.

Pre-operative nutrition assessments do not improve outcomes in cerebral palsy patients undergoing varus derotational osteotomy

Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative.

Feeding problems and malnutrition associated factors in a North African sample of multidisabled children with cerebral palsy

BACKGROUND

In European and North American countries, stunting and malnutrition are common in children with cerebral palsy (CP), especially those with multiple disabilities. The extent of this problem in children with CP in North African countries is still unknown.

AIMS

To evaluate feeding problems and growth in a sample of North African multidisabled children with CP and to determine the factors associated with malnutrition in this population.

METHOD

We conducted a cross-sectional study including multidisabled children with severe CP. Anthropometric measurements (body weight, height, mid-upper arm circumference and triceps skinfold thickness) were performed. In addition, a thorough nutritional survey was conducted including feeding time and the presence of signs in favor of gastrointestinal problems.

RESULTS

We included 40 children, mainly boys (60 %) with a mean age of 6.4 ± 3.7 (range 2-16 years). The nutritional survey had revealed the presence of dysphagia, constipation and gastroesophageal reflux in 55 %, 67.5 % and 70 % of cases, respectively. Sixty-five percent of children had a mealtime over 30 min. Based on World Health Organization (WHO) growth charts, 67.5 % of children were underweight. Forty percent of the children had their weight below the 20th percentile, 5 % and 7.5 % had their height and BMI below the 5th percentile according to CP specific growth charts. Triceps skinfold thickness and mid-upper arm circumference were below the 5th percentile in 50 % and 55 % of cases, respectively. Age (p = 0.047) and constipation (p = 0.003) were identified as predictors of malnutrition.

CONCLUSIONS

Growth parameters and nutritional status are significantly altered in in our sample of North African multidisabled children with CP with a high prevalence of feeding problems represented especially by dysphagia, constipation and GER. Among the studied factors age and constipation may predict the existence of undernutrition.

Experience with a Hybrid Procedure Involving Laparoscopic Fundoplication with Percutaneous Endoscopic Gastrostomy in Chronically Ill Children

Gastrostomy with concurrent laparoscopic Nissen fundoplication (LNF) is often performed as a laparoscopic gastrostomy (LG) by surgeons. Since 2014, we started performing percutaneous endoscopic gastrostomy (PEG) as gastrostomy with LNF. This study aims to compare the outcomes of LG and PEG with LNF. Patients were recruited into two groups: LNF with LG (historical control) or PEG. Demographic data, operation time, time to start feeding, time to full feeding, length of hospital stay (LOS), and complications were compared between the groups. Fourteen patients underwent LNF with LG and 49 underwent LNF with PEG. The median age and body weight of patients were 4.25 years and 14.15 kg in the LG group and 2.58 years and 10.60 kg in the PEG group, respectively. Operation times were significantly shorter in the PEG group (1.81 vs. 2.61 h). The times to start feeding and full feeding as well as LOS were shorter in the PEG group. Nevertheless, complications were similar in both groups. In conclusion, PEG with LNF was associated with significantly shorter operation times, times to start feeding and reach full feeding, and LOS. PEG is a suitable method for LNF in chronically ill children.

Comprehensive approach to children with cerebral palsy

Infantile cerebral palsy is one of the most prevalent diseases and the most frequent cause of disability in paediatrics. Children with cerebral palsy have complex health care needs and often require the care of a multidisciplinary team. However, in many cases there is no paediatrician with overall responsibility for coordinating follow-up. We have produced a support document intended for paediatricians coordinating the care of children with cerebral palsy. Our aim is to provide an ordered compilation of the main issues these patients may develop, to know how to identify and address them if necessary, and to establish criteria for referring these patients to other specialists.

Is There a Role for Elective Early Upper Gastrointestinal Contrast Study in Neurologically Impaired Children following Laparoscopic Nissen Fundoplication?

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11-18.41) years. Mean body weight was 16.22 (3.3-62.5) kg. Mean duration of follow up was 4.15 (0.01-16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

Regional Gastrointestinal Motility in Healthy Children

OBJECTIVE

The aim of the study was to evaluate the safety and use of the 3D-Transit system (Motilis SA, Lausanne, Switzerland) and to describe regional gastrointestinal transit times, segmental colonic transit times, and colonic movement patterns in healthy children.

METHODS

Twenty-one healthy children (11 girls, median age 10.5 years, range 7-15 years) were included. For evaluation of gastrointestinal transit times and colonic movement patterns, we used the minimally invasive electromagnetic 3D-Transit system. A small electromagnetic capsule (21.5 mm × 8.3 mm) was ingested and tracked through the gastrointestinal tract by a body-worn detector. Regional gastrointestinal transit times were assessed as time between capsule passage of anatomical landmarks. Colonic movement patterns were described and classified based on capsule movement velocity, direction, and distance.

RESULTS

One child could not swallow the capsule and 20 children completed the study without any discomfort or side-effects. Median whole gut transit time was 33.6 (range 10.7-80.5) hours, median gastric emptying time was 1.9 (range 0.1-22.1) hours, median small intestinal transit time was 4.9 (range 1.1-15.1) hours, and median colonic transit time was 26.4 (range 6.8-74.5) hours. Median ascending colon/cecum transit time was 9.7 (range 0.3-48.1) hours, median transverse colon transit time was 5.6 (range 0.0-11.6) hours, median descending colon transit time was 2.6 (range 0.01-22.3) hours, and median sigmoid colon/rectum transit time was 7.5 (range 0.1-31.6) hours. Colonic movement patterns among children corresponded to those previously described in healthy adults.

CONCLUSIONS

The 3D-Transit system is a well-tolerated and minimally invasive method for assessment of gastrointestinal motility in children.

[Comprehensive approach to children with cerebral palsy]

Infantile cerebral palsy is one of the most prevalent diseases and the most frequent cause of disability in paediatrics. Children with cerebral palsy have complex health care needs and often require the care of a multidisciplinary team. However, in many cases there is no paediatrician with overall responsibility for coordinating follow-up. We have produced a support document intended for paediatricians coordinating the care of children with cerebral palsy. Our aim is to provide an ordered compilation of the main issues these patients may develop, to know how to identify and address them if necessary, and to establish criteria for referring these patients to other specialists.

Polysomnographic predictors of abnormal brainstem imaging in children

STUDY OBJECTIVES

Evaluation of elevated central apnea-hypopnea index (CAHI) or prolonged central apneas in pediatric patients typically includes neuroimaging with a focus on brainstem pathology. There is little evidence guiding thresholds of polysomnographic variables that accurately predict abnormal neuroimaging. We sought to evaluate whether additional polysomnographic variables may help predict brainstem pathology.

METHODS

A 10-year retrospective review of patients ages 1-18 years who received a brain magnetic resonance imaging (MRI) for an indication of central sleep apnea diagnosed via polysomnography was performed. Demographics, medical history, polysomnogram variables, and MRI results were compared.

RESULTS

This study included 65 patients (69.2% male). The median age was 5.8 years (interquartile range, 3.0-8.3). Most patients had negative (normal or nonsignificant) MRIs (n = 45, 69.2%); 20 (30.8%) had abnormal MRIs. Of the patients with abnormal MRIs, 13 (20.0%) had abnormalities unrelated to the brainstem. Seven patients (10.8%) were found to have brainstem pathology and had a median CAHI of 10.8 events/h (interquartile range, 6.5-21.9), and three of seven (42.9%) had hypoventilation and were more likely to have developmental delay, abnormal neurological examinations, and reflux. Other patients (n = 58) had a median CAHI of 5.6 events/h (interquartile range, 3.1-9.1), and seven (12.1%) had hypoventilation. Area under the curve and receiver operating characteristic curves showed a CAHI ≥ 9.5 events/h and ≥ 6.4% of total sleep time with end-tidal CO₂ ≥ 50 mm Hg predicted abnormal brainstem imaging. Prolonged central apneas did not predict abnormal brainstem imaging.

CONCLUSIONS

Most patients with central sleep apnea do not have MRIs implicating structurally abnormal brainstems. Utilizing a cutoff of CAHI of ≥ 9.5 events/h, ≥ 6.4% total sleep time with end-tidal CO₂ ≥ 50 mm Hg and/or frank hypoventilation, and additional clinical history may optimize MRI utilization in patients with central sleep apnea.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

Prucalopride in intestinal pseudo obstruction, paediatric experience and systematic review

BACKGROUND

Intestinal pseudo obstruction both acute and chronic is an uncommon severe motility disorder that affect both children and adults, can lead to significant morbidity burden and have no standard management strategy. Prucalopride a highly selective serotonin receptor agonist is an effective laxative with reported extra colon action. We aim to report our experience in children with acute and chronic intestinal pseudo obstruction who responded to prucalopride and systemically review the use of prucalopride in intestinal pseudo obstruction.

METHODS

A report of clinical experience and systemic review of the relevant medical databases to identify the outcome of usage of prucalopride in patients with acute and chronic intestinal pseudo obstruction. Studies meeting the selection criteria were reviewed including abstract only and case reports.

RESULTS

All reported cases showed clinical response to prucalopride. There were three full text, two abstracts only and three case reports all reporting clinical improvement with prucalopride.

CONCLUSION

Prucalopride appears to show promising results in children and adults with acute and chronic intestinal pseudo obstruction.

Nutritional Disorders in a Group of Children and Adolescents with Syndromes or Diseases Involving Neurodysfunction

A study of the literature shows the lack of data on a comprehensive analysis of eating disorders in children with neurodysfunction, which constitute a clinical subgroup with an increased risk of abnormalities in this area. Therefore, the aim of this study was to determine the relationship between the coexistence of nutritional disorders and diseases or syndromes associated with neurodysfunction based on data collected during hospitalization at a rehabilitation center for children and adolescents. A retrospective analysis was carried out in a group of 327 children and adolescents aged 4–18 years. The study group covered various types of diseases or syndromes involving damage to the central nervous system. A retrospective analysis of baseline data (age, sex, main and additional diagnosis and Body Mass Index—BMI) was performed. Two assessment criteria of nutritional status were taken into account (z-score BMI and other previously published normative values). In the study group, malnutrition was found more frequently (18.0% of the respondents) than obesity (11.3% of the subjects). Hypothyroidism coexisting with malnutrition was identified in the study group (N% = 43.8%, p = 0.011) and malnutrition with tetraplegia in the subgroup of spastic cerebral palsy (N% = 34.2 %, p = 0.029).

Nutritional composition and cost of home-prepared enteral tube feeding

BACKGROUND & AIMS

To aid in dietary prescription and contribute to the promotion of food and nutritional safety of individuals, this study's objective was to compare the nutritional composition and cost of homemade preparations, blended preparations, and commercial enteral formula prescribed for adults and elderly people at hospital discharge.

METHODS

All hospitals in a Brazilian city that prescribed the three types of enteral formulations provide information about enteral formulations prescribed for home use. Enteral formulations were estimated in relation to energy content, macronutrients, micronutrients, and cost.

RESULTS

Homemade diets, blended and commercial enteral formulations showed, on average, normoproteic, normoglicidic and normolipidic features, with average daily costs (US$/2000 kcal) of US$ 29.77, 50.56 and 154.44, respectively. The cost was higher in the commercial enteral formulas (P < .001); vitamin and mineral content were poorer in homemade preparations.

CONCLUSIONS

The homemade and blended enteral preparations cost less, but were generally lower in micronutrients, calling for more adequate dietary prescription.

The effect of different dietary structure on gastrointestinal dysfunction in children with cerebral palsy and epilepsy based on gut microbiota

BACKGROUND

Gastrointestinal (GI) difficulties are very common among children with cerebral palsy (CP) and comorbid epilepsy. GI function is influenced by dietary structure on gut microbiota. The aim of this study was to compare gut microbiota differences in two dietary groups of this population and examine whether such differences are related to GI dysfunction.

METHODS

Forty children with CP and epilepsy were recruited from a social welfare center, including 23 consuming a fluid diet (liquid diet group) and 17 consuming a normal diet (general diet group). Bacterial DNA was extracted from feces, the V3-V4 region of the 16S rRNA gene was amplified from the DNA, and high-throughput sequencing of the amplified sequences was performed. Microbe prevalence levels were compared on multiple phylogenic levels.

RESULTS

Gut microbial populations differed substantially between the liquid diet group and general diet group. The only two phyla that differed significantly between the two groups were Bacteroidetes (p = 0.034) and Actinobacteria (p = 0.013). Regarding representation of genera, Prevotella species were selectively predominant in the general diet group (25.849% vs. 3.612% in the liquid diet group, p < 0.001), while Bifidobacterium species were selectively predominant in the liquid diet group (24.929% vs. 12.947% in the general diet group, p = 0.013). The gut microbiota of children in the general diet group contained more butyric acid-producing microbiota which was also common in healthy people (e.g. Lachnoclostridium, Dorea, Ruminococcus, Faecalibacterium, Roseburia, and Coprococcus). The gut microbiota of children in liquid diet group however, were rich in symbiotic pathogenic bacteria (e.g. Collinsella, Alistipes, and Eggerthella).

CONCLUSION

The gut microbiota of children with CP and epilepsy consuming a liquid diet had elevated levels of symbiotic pathogens and diminished intestinal barrier protection bacteria, relative to a general diet group. These differences in bacterial microbiota were associated with GI dysfunction symptoms.

The utility of multichannel intraluminal impedance-pH testing in tailoring the management of paediatric gastro-oesophageal reflux disease

AIM

To determine whether combined multichannel intraluminal impedance and pH (MII-pH) testing led to a change in management of children with gastro-oesophageal reflux disease (GORD).

METHODS

Retrospective chart review was done in all patients who underwent MII-pH testing for GORD symptoms at Sydney Children's Hospital between 2008 and 2016. Changes to anti-reflux medications and referral for anti-reflux surgery were evaluated.

RESULTS

There were 365 patients, 260 (71.2%) of whom were on acid-suppressing therapy. The median age was 4.1 ± 4.8 years, 205 patients (56%) were males, 83 (22.7%) were infants (<1 year of age) and 145 (39.7%%) had comorbid conditions. We found 72.1% had abnormal MII-pH results, of which 17.5% had abnormal acid reflux, 8.2% had abnormal number of retrograde bolus movements and 46.3% had hypersensitive oesophagus (positive symptom association only). Infants were significantly more likely to have abnormal MII-pH results compared to older children (P = .04). Results of MII-pH testing led to medication changes in 44.7% and referral for anti-reflux surgery in 6.8% of patients.

CONCLUSION

Combined multichannel intraluminal impedance and pH testing is clinically useful in the management of children with symptoms of GORD and over half the patients had changes to their medical treatment or referral for anti-reflux surgery based on the results of MII-pH testing. It resulted in a treatment change in an additional 32% of patients over traditional pH-metry.

Nissen fundoplication and combined procedures to reduce recurrence of gastroesophageal reflux disease in neurologically impaired children

Neurologically impaired children account for almost half of the fundoplication procedures performed for gastroesophageal reflux disease. Aim of the present study was to report results of antireflux surgery in neurologically impaired children. A retrospective study of neurologically impaired children who underwent fundoplication over a 13-year period (1999–2012) was performed. Recurrence rate, major complications and parents/caregivers perceptions of their child's quality of life following antireflux surgery were analyzed. A total of 122 children (median age: 8 years 9 months; range: 3 months to 18 years) had open “tension-free” Nissen fundoplication, gastrostomy + /− pyloroplasty. Gastroesophageal reflux disease was in all cases documented by at least two diagnostic exams. Median duration of follow-up was 9.7 (1.9–13) years. Three (2.4%) recurrences were documented and required surgery re-do. Major complications were 6%. Seventy-nine of 87 (90%) caregivers reported that weight gain was improved after fundoplication with a median score of 1 (IQR: 1–2). Significant improvement was perceived in postoperative overall quality of life. In this series of fundoplication recurrence incidence was low, serious complications were uncommon and caregivers’ satisfaction with surgery was high. Accurate patient’s selection and creating a “low-pressure” surgical system are mandatory to obtain these results.

Outcomes Associated With Early vs Late Initiation of Exclusive Enteral Feeding Regimens Following Laparoscopic Gastrostomy Tube Placement in the Pediatric Patient

OBJECTIVES

Despite frequent placement of pediatric laparoscopic gastrostomy tubes (GTs), no rigorous evaluation of initial feeding and advancement regimens exists. Therefore, the aim of this study was to determine whether early enteral feeding after GT placement is associated with increased symptoms, procedural complications, or length of stay (LOS).

METHODS

In this retrospective cohort study, the records of all patients at a tertiary care pediatric hospital who had gastrostomy placement were reviewed. Only patients fed exclusively via gastrostomy were included. Feeding was monitored starting with the first postoperative feed and subsequently in 24-hour increments. Adverse events were recorded based on clinical documentation.

RESULTS

A total of 480 patients met inclusion criteria. Patients who started feeds between 24 and 36 hours had a shorter LOS compared with those who started at 36-48 hours (P = .0072) or >48 hours (P < .0001). Patients requiring ≥60 hours to reach goal feeds had significantly longer LOS than the other groups. There was no difference in the distribution of the LOS based on percentage of goal feeds initiated. Patients who required ≥60 hours to attain goal feeds had the most feeding complications.

CONCLUSIONS

More aggressive feeding advancement and earlier initiation of feeds were associated with decreased LOS without an associated increase in adverse clinical events.

Nutritional status and prevalence of dysphagia in cerebral palsy: Usefulness of the Eating and Drinking Ability Classification System scale and correlation with the degree of motor impairment according to the Gross Motor Function Classification System

INTRODUCTION AND OBJECTIVES

Digestive disorders are one of the most common comorbidities among children with cerebral palsy (CP). The aim of this study is to examine the nutritional status of patients with CP, the prevalence of dysphagia by degree of motor impairment, and the impact of digestive disorders on quality of life.

MATERIAL AND METHODS

We conducted a descriptive, cross-sectional, open-label study of outpatients with CP from a tertiary hospital in the Region of Madrid using a structured interview, classifying dysphagia using the Eating and Drinking Ability Classification System (EDACS). We gathered demographical and anthropometric data, and analysed the correlation between severity of dysphagia and functional status as measured with the Gross Motor Function Classification System (GMFCS).

RESULTS

Our sample included 44 patients (65.9% boys), with a mean (standard deviation) age of 9.34 (5) years and a mean BMI of 18.5 (4.9). Forty-three percent presented safety and efficiency limitations (EDACS level>II). Safety and efficiency limitations were associated with more extensive motor involvement (60% had tetraparesis), more varied clinical manifestations (87% had mixed forms) and poorer functional capacity (100% on GMFCS V). The impact on nutritional status increased with higher EDACS and GMFCS scores.

CONCLUSIONS

This is the first study into the usefulness of the EDACS scale in a representative sample of Spanish children and adolescents with CP. Our findings underscore the importance of screening for dysphagia in these patients, regardless of the level of motor impairment, and the need for early treatment to prevent the potential consequences: malnutrition (impaired growth, micronutrient deficiencies, osteopaenia, etc.), microaspiration, or recurrent infections that may worsen patients' neurological status.

Total Oesophagogastric Dissociation in Neurologically Impaired Children: 18 Years' Experience and Long-term Follow-up

OBJECTIVES

Total oesophagogastric dissociation (TOGD) is an alternative antireflux surgery for neurologically impaired children because of a 16% to 38% fundoplication failure rate. This study evaluates TOGD's feasibility and its long-term efficacy both as a Primary and as a "Rescue" procedure after failed fundoplication.

METHODS

Thirty patients (18 boys) who underwent TOGD between 2000 and 2018 in 2 Italian Centres were retrospectively reviewed. Twenty-three were Primary procedures and 7 were "Rescue" ones. Inclusion criteria were severe neurodisability, intractable gastroesophageal reflux, and dysphagia.

RESULTS

Preoperatively, all children had regurgitation, vomiting or retching, and 93% had unsafe swallowing and aspiration, with recurrent chest infections/aspiration pneumonia. Median relative weight was 77% (48%--118%). All patients were taking antireflux medication before surgery. Median age at TOGD was 6.48 years (0.69--22.18). Median follow-up was 3.5 years (0.6-17.7). No recurrence of gastroesophageal reflux (GER) and vomiting was recorded. The number of chest infections and length of hospital stay showed a significative decrease (P value <0.0001 for both), whereas median relative weight reached 101% (P value 0.002). Parents'/caregivers' perception of outcome showed a significative improvement. Six patients (20%) experienced early complications and 3 required surgical intervention. Three late complications (10%) also required surgery. There was no surgery-related mortality.

CONCLUSION

TOGD is an effective procedure with an acceptably low complication rate for children with severe neurological impairment and is followed by a major improvement in general health and quality of life for children and families. There was no substantial difference in outcome between Primary and "Rescue" procedures.

Oral hygiene and oral status of institutionalized children with motor and intellectual disabilities

The oral hygiene and oral status of children with severe disabilities with both nutritional and respiratory complications who were institutionalized at Karugamonoie (KNI), a facility for children with disabilities, were investigated in this study. Their oral hygiene management was solely dependent on caregivers and nurses at the institution. Thirty children (13 females, 17 males; average age, 7.6 years) who had a tracheotomy and feeding tube (gastrostomy, nasogastric, or jejunostomy feeding tube) were included in the study. As for oral characteristics, poor control of tongue movement, anterior open-bite, abnormal strain of facial muscles, dry mouth, and swallowing dysfunction were found in 63.3%, 63.3%, 13.3%, 20.0%, and 100.0%, of the children, respectively. The mean ± standard deviation Decayed, Missing, Filled Teeth score was 0.13 ± 0.57. The Gingival Index (GI) showed that the children had mild (53.3%) to moderate (46.7%) gingivitis. The Simplified Oral Hygiene Index was excellent in 50.0% of the children, good in 23.3%, fair in 20.0%, and poor in 6.7% of the children. These indices were satisfactory in general except for GI management, which may have been hampered by abnormal oral functions and anterior open-bite. In conclusion, oral hygiene management of children with nutritional and respiratory complications at KNI was shown to be of high quality even without on-site intervention by dental specialists.

Nutritional status of neurologically impaired children: Impact on comorbidity

BACKGROUND AND AIMS

Malnutrition is common in neurologically impaired (NI) children. It is, however, ill-defined and under-diagnosed. If not recognized and treated, it increases the burden of comorbidities and affects the quality of life of these children. The aim of this study was to characterize the nutritional status of a cohort of children followed up at a reference center for cerebral palsy (CP) in Brussels, Belgium, and to investigate possible links with the occurrence of comorbidities.

MATERIAL AND METHODS

We conducted a single-center retrospective study including all the children followed up at the Inter-university Reference Center for Cerebral Palsy ULB-VUB-ULg. The data were obtained by reviewing medical files. Anthropometric measurements as well as the etiology of neurological impairment, comorbidities, feeding patterns, and laboratory test results were collected. The children were assigned a nutritional diagnosis according to the World Health Organization and Waterlow definitions.

RESULTS

A total of 260 children with cerebral palsy were included, 148 males and 112 females. Their mean age was 10.9±4.3 years. The gross motor function classification system (GMFCS) level was I for 79 children, II for 63 children, III for 35 children, IV for 33 children, and V for 50 children. Of the children, 54% had a normal nutritional status, 34% showed malnutrition, and 8% were obese; 38% had oropharyngeal dysphagia. The sensitivity of mean upper arm circumference of<p10 to detect severe malnutrition was 95%. Specific growth charts for CP were neither sensitive nor specific for predicting the risk of comorbidities. Malnutrition was associated with an increased risk of comorbidities (relative risk of 2.4 [1.7; 3.4]). It was also associated with the occurrence of pneumonia, pressure ulcers, and pathological bone fracture.

DISCUSSION AND CONCLUSION

Children who are NI should be systematically and thoroughly screened for malnutrition, in the hope of offering early nutritional support and reduce comorbidities.