Clinical response to short-term nasogastric feeding in infants with gastroesophageal reflux and growth failure

The impact of different medical complications on the feasibility of removing the feeding tube from infants with dysphagia

PURPOSE

This study examined whether certain medical complications influence the feasibility of tube removal.

METHODS

42 subjects with dysphagia who were under the age of 2.5 years were nourished entirely through feeding tubes. Additionally, they were judged to have no aspiration. The following data about the infants were collected through a retroactive survey: age at which oral feeding training commenced, gender, and whether certain medical complications (cardiovascular, respiratory, digestive, neurological, or oral) had been present at birth. The data were analyzed to determine which type of medical complication affected the likelihood of removing the feeding tube from the infant at 3 years of age.

RESULTS

Of the five medical complications examined, cardiovascular complications significantly affected the feasibility of tube removal (p = 0.049).

CONCLUSION

Pediatric dysphagia patients with cardiac complications, compared to those with other complications, may take longer to transition off tube feeding.

Prokinetics prescribing in paediatrics: evidence on cisapride, domperidone, and metoclopramide

OBJECTIVES

Domperidone and metoclopramide are prokinetics commonly prescribed off-label to infants and younger children in an attempt to treat gastro-oesophageal reflux symptoms. Another prokinetic drug, cisapride, was used but withdrawn in 2000 in the United Kingdom because of serious arrhythmic adverse events. Medicines and Healthcare Products Regulatory Agency issued safety warnings for domperidone in May 2012 and restricted its indications. We report here national primary care prescribing trends and safety signals of these drugs in children.

METHODS

We used data from the General Practice Research Database between 1990 and 2006 for children <18 years. Descriptive statistics and Poisson regressions were performed to characterise prescribing trends. We examined safety signals in nested case-control studies.

RESULTS

The proportion of children <2 years old being prescribed one of the medications doubled during the study period. Prescriptions of domperidone increased 10-fold, mainly following the withdrawal of cisapride in 2000. Prescriptions of metoclopramide did not change significantly. Despite the increase in prescriptions of domperidone, no new safety signals were identified.

CONCLUSIONS

These data showed dramatic changes in prescribing of cisapride and domperidone despite the lack of good-quality supporting evidence. It is possible that these prescribing trends were influenced by published guidelines. Even if produced without robust efficacy and safety evidence, published guidelines can influence clinicians and consequently affect prescribing. Therefore, improving the evidence base on prokinetics to inform future guidelines is vital. The lack of new safety signals during this period would support the development of suitable powered clinical studies.

Maternal psychopathology and psychomotor development of children with GERD

OBJECTIVES

The relation between gastroesophageal reflux disease (GERD) and maternal psychopathology as well as the role of impairments in mother-child interactions in the perpetuation of feeding problems in children with GERD was previously implicated but not confirmed. The present study aimed to study the relation between maternal psychopathology and feeding problems in children with GERD and the effects of GERD on the psychomotor development of children.

SUBJECTS AND METHODS

The case group included 39 children with GERD and their mothers and the comparison group included 39 healthy children and their mothers. The groups were matched for age, gestational age, socioeconomic status, and sex. Scales used for the psychiatric assessment of mothers were the Beck Anxiety Inventory, Hamilton Rating Scale for Depression, Eating Attitudes Test, and Experiences in Close Relationships-Revised. The children's developmental levels were assessed by the Brunet-Lezine Revised test.

RESULTS

Maternal Beck Anxiety Inventory, Hamilton Rating Scale for Depression, Eating Attitudes Test, and Experiences in Close Relationships-Revised scores were significantly higher in the case group. Forced feeding and maternal thoughts of the child's feeding as insufficient were associated with a high level of maternal attachment-related anxiety and avoidance. Children with GERD had significantly lower Brunet-Lezine-Revised scores.

CONCLUSIONS

Maternal psychopathology, especially insecure attachment, may play a role in the feeding problems in children with GERD. Children with GERD should be examined for maternal psychopathology and feeding problems so that maladaptive feeding behaviors can receive appropriate intervention before the development of negative reinforcement to feeding. The psychomotor development of children should be kept in mind.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Recent advances in biliary atresia: prospects for novel therapies

BACKGROUND

Biliary atresia (BA) is a progressive fibro-obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction before 2 months of age. Untreated BA is a uniformly fatal disease and even with our current therapies only 50% of children with BA will be transplant-free by 2 years of age. Despite descriptions of this disorder dating back to the 1800s our current therapies are palliative. They focus on prompt diagnosis, supportive nutritional care and interventions for sequelae.

OBJECTIVE

To present the literature supporting current treatment strategies and potential future therapies.

METHOD

Each of the aspects of care is described and the literature about nuances of care is provided.

CONCLUSION

Therapies will not improve outcomes until novel treatments are introduced, such as those suggested, which may intervene in the inflammatory or fibrotic steps of the disease process.

Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis

OBJECTIVE

Chronic gastrointestinal symptoms and histologic changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux disease (GERD) may be improved by the use of elemental formulas. The aim of our study was to evaluate the efficacy of a dietary trial in neurologically impaired children unresponsive to medical and surgical therapy for GERD.

METHODS

Nine children (three boys and six girls; median age, 44 months; range, 13-180 months) affected by cerebral palsy associated with severe mental retardation and with long-standing history of GERD were fed the elemental formula, Neocate, for a minimum of 4 weeks. Before and after the dietary trial, each child underwent endoscopy with esophageal biopsy and a cellobiose/mannitol sugar permeability test. The diagnosis of GERD was based on the microscopic changes of the esophagus.

RESULTS

Before the dietary trial, according to conventional histologic criteria, esophagitis was considered moderate in seven children and mild in two. Five of nine patients also had abnormal sugar permeability test results. During and after the dietary trial, seven of nine patients experienced resolution of their long-term symptom complaints. Furthermore, after the dietary trial, both endoscopic ( < 0.01) and histologic ( < 0.05) findings significantly improved. At 6-month follow-up, progressive reintroduction of individual dietary proteins, except for cow's milk protein, did not cause reappearance of the symptoms.

CONCLUSIONS

In neurologically impaired children unresponsive to conventional antireflux treatments, a course of a highly restricted diet with an amino acid-based formula may bring an immediate and sustained, endoscopically and histologically proven improvement in long-standing gastrointestinal symptoms and esophagitis.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Reflux in children

Gastro-oesophageal reflux (GOR) is an extremely common paediatric problem that often runs a harmless and self-limited course. Physiological GOR however can lead to marked parental anxiety, many unnecessary investigations and often unwarranted and potentially harmful therapeutic interventions. Our ability to better define GOR and gastro-oesophageal reflux disease (GORD) has improved in the past 15 years with a better understanding of the pathophysiology in infants and children due to the development and wider use of flexible endoscopy, 24-hour oesophageal pH monitoring and, more recently, the use of micromanometric methods for studying oesophageal motility. This will be further enhanced in the future with the development of non-invasive breath testing to study gastrointestinal motility and the use of electrical impedance to study fluid movement. Our therapeutic interventions have also improved particularly in the areas of acid suppression, improved surgical techniques and most recently laparoscopic fundoplication. This chapter reviews these advances in the paediatric area especially with regard to pathophysiology, diagnostic testing and therapeutic intervention.

Gastroesophageal reflux disease in children

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.

Randomised trial of different rates of feeding in acute diarrhoea

OBJECTIVE

To compare the effect of different feeding frequencies on the speed of recovery from diarrhoea.

METHODS

A randomised, non-blinded trial provided 0.452 MJ/kg/day as either 6 or 12 feeds of cows' milk each day to 262 hospitalised male infants aged 3-12 months with acute diarrhoea. Stool frequency, stool weight, body weight, and diarrhoea complications were monitored until recovery or for 14 days.

RESULTS

A proportional hazards regression model controlling for age, diarrhoea aetiology, and severity of dehydration on admission revealed that the frequently fed group had a significantly shorter duration of diarrhoea (hazards ratio, 1.29; 95% confidence interval, 1.002 to 1.653). Frequently fed infants had a significantly greater weight gain and significantly lower faecal frequency and faecal weight.

CONCLUSIONS

Breast feeding remains the preferred method of feeding infants with acute diarrhoea, but feeding cows' milk to adequately nourished infants with acute diarrhoea is safe and is more rapidly effective if provided in frequent feeds with low energy loads.

Gastroesophageal reflux in children

Gastroesophageal reflux (GER) is a common disorder in infants and children with a high rate of spontaneous resolution. Some children, however, will continue to have problems and progress from functional GER to pathogenic GER. In children with functional GER, diagnostic testing and pharmacologic treatment is unnecessary. In more involved cases, there are a number of tests available that help to quantify and qualify the extent of disease. Treatment begins with conservative measures and progresses to acid neutralization/supression and medications to enhance motility. Should medical management fail to control the consequences of reflux disease, surgical intervention is warranted.

Gastrointestinal problems in the neurologically impaired child

Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux, with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children. Early recognition of an infant with neurological impairment that is compromising the normal feeding process is crucial. Detailed assessment of the nature of the feeding difficulties will help to predict the anticipated future nutritional needs and will allow decisions to be made about the appropriateness of input from different professionals (speech therapy, dietitians, gastroenterologists). Only when such information has been carefully assembled will rational and directed medical and surgical therapy be possible. Nutritional rehabilitation of disabled children can be associated with increased mortality and morbidity secondary to gastro-oesophageal reflux, retching, dumping syndrome or aspiration. It may also entail an increased work for care givers and increase costs of care. It is therefore necessary to document the impact of such rehabilitation on growth and quality of life for both patient and care giver.

Percutaneous endoscopic gastrostomy without an antireflux procedure in neurologically disabled children

In children with major neurologic impairment, gastrostomies are often used to alleviate malnutrition and feeding difficulties. There has been a trend toward performing "protective" antireflux surgery in these children. Nineteen children with major neurologic impairment and feeding failure were prospectively evaluated and followed up after placement of a percutaneous endoscopic gastrostomy (PEG) without any antireflux procedure. Mean age at PEG placement was 34 months with mean follow-up of 20.7 months. All parents would recommend PEG to families with disabled children, and if given the chance, 95% would elect PEG again for their child. No child developed choking, gagging, or retching postoperatively. At the time of follow-up, postoperative gastroesophageal reflux did not appear to be a major clinical problem.

Changing trends in feeding policies for ventilated preterm infants

In 1987 and 1994 all UK regional neonatal intensive care units were questioned about their feeding policies for the ventilated preterm infant. Between 1987 and 1994 there was an increase in the use of milk feeds (59 versus 71%), fortified breast milk (5 versus 72%) and low birthweight formula (41 versus 69%) whilst use of donor breast milk declined (56 versus 22%). Units that gave enteral feeds used significantly less parenteral nutrition (p < 0.05). Overall there was a tendency towards greater uniformity in feeding policies.

Gastroesophageal reflux. Diagnostic and therapeutic approaches

The clinical challenge of determining the medical conditions that are associated with obvious symptoms of gastroesophageal reflux and what diagnostic tests are appropriate to define this relationship is substantial. To determine which infants may be suffering from pathologic conditions associated with subtle signs of gastroesophageal reflux is even more challenging. This determination is essential to avoid subjecting many healthy infants to costly and potentially invasive testing. This article focuses on the physiology, clinical presentations, diagnosis and evaluation, and therapy of gastroesophageal reflux.

Respiratory manifestations of gastroesophageal reflux disease in pediatric patients

Respiratory manifestations of gastroesophageal reflux disease (GERD) are being recognized with increasing frequency. We present the evaluation and management of four infants and children with unusual respiratory symptoms attributed to GERD. The advantages and disadvantages of diagnostic studies of GERD are discussed, and an evaluation and treatment protocol is presented. Treatment must be tailored to the nature and severity of the patient's presenting symptoms and includes conservative, pharmacologic, and/or surgical management.

Functional vomiting disorders in infancy: innocent vomiting, nervous vomiting, and infant rumination syndrome

Pediatric gastroenterologists have tended to view gastroesophageal reflux (GER) as a disease in and of itself--a disease that can be diagnosed "objectively" with use of numerical data from esophageal pH monitoring and cured with pharmacologic or surgical treatment. What is often forgotten is that the data derived from esophageal pH monitoring and other techniques may identify the presence of abnormal GER but tell nothing about its pathogenesis. The usual approach to infants who feed poorly, vomit, or fail to gain weight is to identify the presence of abnormal GER, rule out underlying organic causes of vomiting, and then diagnosis primary GER disease. The baby is then treated with pharmacologic, dietary, or positional therapy and, ultimately, if these therapies fail to eradicate the symptoms attributed to GER, surgical fundoplication, which stops vomiting regardless of its causes. The pediatric literature on infant vomiting and GER is almost devoid of research into the nature and possible relationships among infant stress, vomiting, feeding difficulties, and failure to grow. Clinically, the quality of the maternal-infant relationship is frequently approached superficially, with psychosocial aspects treated as less important in infants considered to have primary organic disease amenable to medical or surgical treatment. Psychosocial factors in the pathogenesis of the infant's symptoms are often not pursued beyond assessment for possible abuse or neglect. It has been known for centuries that stress or excitement affects gastrointestinal function and symptoms. Although the field of infant psychiatry has produced a substantial literature on the nature of stresses that affect both infants and mothers, the pediatric literature on vomiting and failure to thrive seldom acknowledges the existence or importance of these contributions. In clinical practice, failure to explore psychosocial aspects that may contribute to vomiting, feeding difficulties, or failure to thrive may result in missed opportunities for less invasive, more effective therapy at best, and countertherapeutic treatment at worst. This article describes three functional vomiting disorders of infancy, their distinguishing characteristics, hypotheses regarding their pathogenesis, and principles of comprehensive management.

Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children

The impact of nutritional rehabilitation on gastroesophageal reflux (GER) in 10 malnourished neurologically impaired children (NIC) was studied (mean age, 9.1 +/- 3.1 years). None of the children had an antireflux procedure (ARP), and all were fed exclusively through a percutaneous endoscopic gastrostomy (PEG). Malnutrition was defined as triceps skin fold thickness (TSF) below the fifth percentile for age and sex. GER was established using standard criteria for a 24-hour pH probe study. All children were treated with an H2 antagonist and a prokinetic agent, along with aggressive nutritional rehabilitation. When TSF was > or = 50th percentile, medications were stopped, and the 24-hour pH probe study was repeated. The mean weight gain was 8.8 +/- 3.7 kg over 8.4 +/- 2.3 months. The 24-hour pH probe study showed marked improvement after nutritional rehabilitation in six of 10 children. These children remained asymptomatic throughout long-term follow-up, without the use of medications. Two children had abnormal pH probe results and worsening clinical symptoms when taken off medications after nutritional rehabilitation. They were reexamined after reinstituting the prokinetic drug; results of the pH probe study were normal, and there was no clinical symptomatology. The patients were then given long-term medication. Two children (one with erosive esophagitis and one with persistent symptoms) underwent ARP. We conclude that despite accompanying GER, successful nutritional rehabilitation can be achieved in malnourished NIC, using PEG feeding and antireflux medication. Although some NIC with GER may need an ARP or long-term medication, in most malnourished NIC nutritional rehabilitation is associated with resolution of GER.

The effect of tube feeding on postprandial gastroesophageal reflux

Distal esophageal pH in supine position was monitored for 6 hours in 13 asymptomatic infants. During this period the patients received 15 to 20 mL/kg of 5% glucose solution twice every 3 hours. Each meal was fed orally or through a pH sensor tube. When the patient was fed through a tube, the meal was introduced into the stomach or into the distal esophagus. The extent of reflux during 2 hours after feeding was compared between oral and tube feeding. Comparing oral and intragastric tube feeding, intragastric tube feeding showed significantly fewer reflux events, a smaller percentage of time in the esophageal pH below 4, and a shorter duration of the longest single reflux event. Comparing oral and intraesophageal tube feeding, intraesophageal tube feeding showed the same pattern. The data indicated that tube feeding significantly diminishes the postprandial reflux.

Gastrostomy and Nissen fundoplication in neurologically impaired children

We report our experience with 90 neurologically impaired children treated with gastrostomy and Nissen fundoplication. Malnutrition was the main problem, followed by aspiration, recurrent pneumonia, and vomiting. The symptomatology was caused by swallowing incoordination and gastroesophageal reflux. The diagnosis of gastroesophageal reflux was confirmed by upper gastrointestinal series and pH probe. Nissen fundoplication was performed following a standard technique with preservation of the vagus nerves and its branches, repair of the diaphragmatic crura, reconstruction of the angle of His, and a 360 degree wrap. A gastrostomy and pyloroplasty or pyloric dilatation were part of the operative procedure. There were no deaths and few complications related to the surgical procedure. Marked nutritional improvement was seen in most cases with an average weight gain of 3.2 kg/patient 3 months following surgery. There was also improvement in milestones and seizure control. The majority of parents were very satisfied and would recommend the procedure to other parents with similar problems.

Home teaching of nocturnal nasogastric feeding

Nocturnal nasogastric feeding (NGF) supplementation is an effective means of supplying calories to children with chronic diseases which may impair caloric and nutritional intake. Herein, we describe our experience with 18 patients who were taught NGF. They were divided into two groups: one group was instructed in the hospital which is the typical situation, whereas the second group was instructed at home. No complications were associated with NGF taught either at home or in the hospital. Our experience, therefore, indicates that nocturnal NGF can be successfully taught at home.

Nutritional support for the infant with extrahepatic biliary atresia

Some infants with biliary atresia obtain dramatic improvement for prolonged periods after the performance of hepatic portoenterostomy. Such infants may have life styles not substantially different from those of normal children. In others, the benefit from this operation, if any, is short lived. These infants are very vulnerable to the debilitating effects of severe, prolonged malabsorption and ultimately require orthotopic liver transplantation to sustain life. The physician caring for infants awaiting liver transplantation can do much, not only to prolong survival but to maintain satisfactory growth and development. The key consideration is to provide adequate nitrogen and nonnitrogen calories, liberally utilizing modern methods of enteral alimentation when necessary. In addition, attention must be directed toward several vitamin and mineral deficiencies, particularly those of the fat-soluble vitamins, that inevitably accompany severe malabsorption in children. Management of extrahepatic biliary atresia in infants is difficult and requires meticulous attention to details. Nevertheless, the long-term cure of this disorder provided by liver transplantation makes their care a rewarding experience.

Tube feeding of infants and children

Advances in tube feeding methods, equipment, and formulas have helped to make this form of nutritional support appropriate for and well tolerated by children with a wide variety of clinical problems. This article describes advances in the field of enteral feeding and discusses the management of common problems associated with this technique.