Teaching about children with medical complexity: A blueprint for curriculum design

Children with medical complexity make up a small portion of the pediatric population but utilize a large percentage of health care time and spending. The medical needs of children with medical complexity are highly variable and the education of healthcare providers in the care of these children has taken on more significance. Designing curricula and educational innovations related to the care of children with medical complexity can be challenging. Familiarity with the sociocultural theory, the zone of proximal development, Kolb's experiential learning model, and the educational resources that already exist allow for more ease in developing a curriculum that fits the needs of learners who may have a wide range of exposure to children with medical complexity. Flipped classroom models, simulations, asynchronous modules, and home and community experiences are all useful learning modalities to provide a varied and important curriculum. Taking advantage of the knowledge and skills of the many different members of the multi-disciplinary team caring for children with medical complexity is an important educational strategy that provides benefits to the learners and can enhance interprofessional education.

Feeding and nutrition in children with medical complexity

Providing adequate and appropriate nutrition to children with medical complexity (CMC) is often a challenging task. These patients are a diverse group whose varying nutritional needs must be carefully assessed and monitored. Optimal feeding and nutrition strategies in CMC require an individual approach and may include oral, enteral (gastric or jejunal), or parenteral provision of nutrients. Complications of enteral feeding, including those associated with medical devices such as feeding tubes, are common, and provider familiarity with some of the more common complaints is helpful. We provide here a summary of different feeding approaches, with exploration of the rationale for each, as well as discussion of common complications and some practical troubleshooting tips.

Postfundoplication retching: Strategies for management

BACKGROUND

Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right.

METHODS

A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered.

CONCLUSIONS

Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided.

LEVEL OF EVIDENCE

II-V.

Does retching matter? Reviewing the evidence-Physiology and forces

Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.

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

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

Laparoscopic fundoplication in neonates and young infants: Failure rate and need for redo at a high-volume center

AIM OF THE STUDY

Present the outcomes of patients younger than 2years who underwent laparoscopic fundoplication, highlighting the failure rate and need for redo fundoplication.

METHODS

Retrospective review of patients <2years who underwent laparoscopic fundoplication between January 2009 and December 2014.

MAIN RESULTS

458 infants younger than 2years underwent laparoscopic fundoplication in the 6-year period (360 Nissen, 77 Toupet and 21 Thal fundoplications). Median age at surgery was 5 (1-23) months. Median follow-up was 3 (1-6) years. The conversion rate was 0.87% (4 of 458 cases). Patients did not undergo routine studies to assess the incidence of postoperative GER but were instead followed clinically. Failure of the fundoplication was determined when a patient was unable to gain weight and/or protect the airway while receiving gastric feedings because of GER. The failure rate in our experience was 2.6% (12 redo out of 458 cases [11/360 Nissen, 1/77 Toupet and 0/21 Thal]). All failed cases occurred because of migration of the fundoplication, confirmed preoperatively by a contrast study. Median time between the initial fundoplication and the redo was 13 (5-27) months. There were no failures within a contemporaneous group of 101 patients <2years who underwent open fundoplication.

CONCLUSION

The need for a redo fundoplication after a laparoscopic fundoplication was an uncommon event in our experience (12 of 458 cases). Our results contrast with published studies that report higher failure rates. Case volume per surgeon may explain in part the dissimilar results among studies.

LEVEL OF EVIDENCE

III.

Nissen fundoplication in children with and without neurological impairment: A prospective cohort study

BACKGROUND

It is assumed that children with neurological impairment (NI) have inferior results after fundoplication compared to those without NI (non-NI). The aim of this study was to assess outcome after fundoplication in children with and without NI.

METHODS

87/105 patients (46 NI, 41 non-NI) undergoing fundoplication between 2003 and 2009 were included in this prospective two-center cohort study. Complications occurring within the first 30days were scored from 0 to 100 by the comprehensive complication index (CCI). Follow-up included clinical examination, upper gastrointestinal contrast study and 24-h pH monitoring 6months postoperatively, then phone-interviews 1, 2 and 4years later.

RESULTS

There were no statistical differences in age (NI 3.1 years [0.2-15.2] vs non-NI 5.0 years [0.4-15], p=.14) or in total CCI score (NI 20.9 [0-44.9] vs non-NI 8.7 [0-40.6], p=.57). Hospital stay was longer for NI children (9days [4-57] vs non-NI: 4days [2-16], p<0.001). More than 90% of parents in both groups reported that the fundoplication had improved the child's overall condition. Recurrence of gastroesophageal reflux disease (GERD) was diagnosed in 12 NI and 7 non-NI patients (p=.31).

CONCLUSIONS

Early complications, GERD recurrence, and long-term parental satisfaction after fundoplication did not differ between NI and non-NI patients.