Timing of gastrostomy insertion in children with a neurodisability: a cross-sectional study of early versus late intervention

Early Tube Feeding Improves Nutritional Outcomes in Children with Neurological Disabilities: A Retrospective Cohort Study

Tube feeding is a life-saving treatment for children with neurological disabilities (ND), who often suffer from malnutrition and feeding disorders. Nonetheless, it is still not widely used. Our aim was to evaluate the outcomes of exclusive tube feeding in a cohort of ND children. All consecutive ND children who started tube feeding at our center within the last 5 years were included in this retrospective study. Weight-for-age, body mass index (BMI), mid-upper arm circumference (MUAC) Z-scores, and symptoms were collected at baseline (V0), 6 (V1), and 12 months (V2) after gastrostomy placement. Fifty children (62% males) were included. The ND-underlying disease was genetic (n = 29, 58%), hypoxic-ischemic encephalopathy (n = 17, 34%), or metabolic (n = 4, 8%). Indications for tube feeding were malnutrition (n = 35, 70%), recurrent respiratory infections (n = 11, 22%), or both (n = 4, 8%). Enteral formulae were polymeric (n = 29, 58%), semi-elemental (n = 17, 34%), hypercaloric (n = 3, 6%), or elemental (n = 1, 2%). Homemade blended feed was offered to three children (6%) in addition to the formula. Weight and BMI increased over the study period. Except for constipation, all symptoms (cough, vomiting, and diarrhea) improved at 6 and 12 months (p < 0.05). Non-serious complications (n = 8; track disruption, granuloma, and skin infection) were observed. Longer disease duration (p < 0.001) at the start of tube feeding was associated with the absence of normalization of nutritional status (BMI Z-score > 2 SD) at 12 months. Tube feeding with commercially available enteral formulae should be started as early as possible for better outcomes.

Rate of paediatric gastrostomy insertion in England and relationship to epidemiology of cerebral palsy

Background and objectives

Gastrostomy tubes are commonly used to provide an alternative route for enteral nutrition. Most of the gastrostomies are inserted in children with cerebral palsy. Previous studies have shown an increase in insertion rate, however, epidemiological studies reveal a stasis in prevalence of cerebral palsy. We aimed to provide an up-to-date rate of gastrostomy insertion in children in England over a 20-year period and systematically review the prevalence of cerebral palsy to ascertain an epidemiological explanation for insertion trends.

Methods

Retrospective search of Hospital Episode Statistic, a database held diagnosis and procedural code from all England National Health Service hospitals from 2000 to 2021 using International Classification of Disease-10 and Office of Population Censuses and Survey's Classification-4. England Office for National Statistics data were used for population census. MEDLINE and EMBASE were systematically searched for epidemiology of cerebral palsy.

Results

There were 23 079 gastrostomies inserted in children <15 years in England (2000-2021) leading to a frequency of 12.4 insertions per 100 000 children per year and 1383 gastrostomy insertions in 15-18 years age group (6 per 100 000). The overall gastrostomy insertion rate in children <15 years has increased from 3.7 procedures per 100 000 in 2000 to 18.3 per 100 000 in 2017. Prevalence of cerebral palsy remained stable (1.5-3.3 per 1000 birth) since 1985.

Conclusions

There was a significant increase in the rate of gastrostomy insertion in children in England during most of the last 20 years not explained by a stable prevalence of cerebral palsy.

Clinical characteristics of children with severe neurologic impairment: A scoping review

OBJECTIVE

The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies.

METHODS

Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics.

RESULTS

We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials.

CONCLUSIONS

Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.

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.

Paediatric gastrointestinal endoscopy: Experience in Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

Background. Endoscopy is an important diagnostic and therapeutic mode of management in children with gastrointestinal disorders. Objective. To determine the indications, endoscopic yields and impact of the service on the ongoing health and complications among children who underwent gastrointestinal endoscopy at Red Cross War Memorial Children’s Hospital, Cape Town. Methods. A 10-year (2007 - 2016) retrospective study of children <18 years old who underwent gastrointestinal endoscopy was undertaken using relevant patients’ variables obtained from their hospital medical records. Data were analysed using Stata 13.1 (p<0.05). Results. A total of 402 children underwent a total of 695 gastrointestinal endoscopic procedures: 592 (85.2%) were gastroscopies, 78 (11.2%) combined gastroscopies with colonoscopies and 25 (3.6%) colonoscopy-only procedures, respectively. The main diagnostic indications for gastroscopy, gastroscopy combined with colonoscopy and colonoscopy-only were chronic abdominal pain (n=49; 12.2%), suspected inflammatory bowel disease (n=30; 7.5%) and rectal bleeding (n=13; 52.0%) respectively. The most common therapeutic indication for gastroscopy was change of a percutaneous endoscopic gastrostomy (n=143; 35.6%) while for colonoscopy 6 (5.8%) had polypectomy. Abnormal histopathological results were made from both macroscopically normal- and abnormal-looking tissues, though with no statistically significant relationship. Conclusion. Endoscopy offers diagnostic and therapeutic options in children. Positive histological findings were obtained in some cases where gastrointestinal mucosae appeared normal. There is need to obtain biopsies from both macroscopically normal- and abnormallooking gastrointestinal mucosae as positive histological findings could be made from them and hence improve diagnostic yield.

Top-ten tips for managing nutritional issues and gastrointestinal symptoms in children with neurological impairment

The prevalence of children with neurological impairment (NI) presenting feeding difficulties and gastrointestinal symptoms is rising. The most recent guidelines recommend early nutritional assessment and intervention in order to prevent undernutrition and growth failure, along with the proper diagnosis and treatment of some frequent gastrointestinal symptoms, such as gastroesophageal reflux disease (GERD) and constipation, which can further worsen the feeding process and nutritional status. Nonetheless, the nutritional issues and growth deficits of children with NI are often considered to be of low priority or under recognised by healthcare providers. The present article proposes ten top tips that highlight the major points along the nutritional management pathway of NI children. The implementation of these tips in all healthcare settings could potentially improve patient outcomes and reduce morbidity and mortality.

Failure to Thrive Hospitalizations and Risk Factors for Readmission to Children's Hospitals

OBJECTIVES

Risk factors for failure to thrive (FTT) readmissions, including medical complexity, have not been described. We sought to characterize children hospitalized for FTT and identify risk factors associated with FTT-specific readmissions during the current era of increasing medical complexity among hospitalized children.

METHODS

This retrospective cohort study used the Pediatric Health Information System database of 43 freestanding children's hospitals across the United States. The cohort included children <2 years of age with index hospitalizations for FTT between 2006 and 2010. The main outcome was FTT-specific readmission within 3 years. Using Cox proportional hazards models, we assessed the association of demographic, clinical, diagnostic, and treatment characteristics with FTT-specific readmission.

RESULTS

There were 10 499 FTT hospitalizations, with 14.1% being readmitted for FTT within 3 years and 4.8% within 30 days. Median time to readmission was 66 days (interquartile range, 19-194 days). Nearly one-half of children (40.8%) had at least 1 complex chronic condition (CCC), with 16.4% having ≥2 CCCs. After multivariable modeling, increasing age at admission, median household income in the lowest quartile (adjusted hazard ratio, 1.23 [95% confidence interval, 1.05-1.44]), and prematurity-related CCC (adjusted hazard ratio, 1.46 [95% confidence interval, 1.16-1.86]) remained significantly associated with readmission.

CONCLUSIONS

Nearly one-half of children hospitalized for FTT had a CCC, and a majority of FTT-specific readmissions occurred after the traditional 30-day window. Children with prematurity-related conditions and low median household income represent unique populations at risk for FTT readmissions.

A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review

CONTEXT

Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting.

OBJECTIVE

To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes.

DATA SOURCES

Medline, Embase, and Cochrane Register databases searched from inception to March 2014.

STUDY SELECTION

Articles examining health outcomes of neurologically impaired children living with feeding tubes.

DATA EXTRACTION

Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development.

RESULTS

We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes.

LIMITATIONS

We were unable to investigate effect size of outcomes because quantitative data were not collected.

CONCLUSIONS

The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.