Dysphagia and gastroesophageal reflux disease: dilemmas in diagnosis and management in children with neurological impairment

Respiratory Comorbidities and Complications of Cerebral Palsy

Respiratory complications are the most frequent cause of morbidity, mortality, and poor quality of life in children with cerebral palsy (CP) and represent the leading cause of hospitalizations. Several factors negatively influence the respiratory status of these children: lung parenchymal alterations and factors modifying the pulmonary pump function of chest and respiratory muscles, as well as concomitant pathologies that indirectly affect the respiratory function, such as sleep disorder, malnutrition, epilepsy, and pharmacological treatments. Early management of respiratory complications can improve the global health of children with CP and enhance quality of life for them and their caregivers.

Pneumonia after hip surgery in children with neurological complex chronic conditions

AIM

In children with neurological complex chronic conditions (CCC) undergoing hip surgery we aimed to: estimate the rate of postoperative pneumonia, determine the effect of pneumonia on postoperative hospital resource use, and identify predictors of postoperative pneumonia.

METHOD

A retrospective cohort study was conducted utilizing the Pediatric Health Information System database for 2609 children (1081 females, 1528 males) aged 4 years and older with a neurological CCC who underwent hip surgery (i.e. reconstruction surgery or salvage procedure) between 2016 and 2018 in 41 US children's hospitals. Multivariable, mixed-effects logistic regression was used to assess patient characteristics and risk of pneumonia.

RESULTS

Mean age at hip surgery was 10 years 1 month (SD 4y 8mo). The postoperative pneumonia rate was 1.6% (n=42). Median length of stay (LOS) was longer for children with pneumonia and the 30-day all-cause unplanned readmission rate and costs were higher. Variability in rates of pneumonia ranged from 1.1% to 2.8% across hospitals. Significant predictors of postoperative pneumonia were osteotomy type (p=0.005) and number of chronic conditions (p≤0.001).

INTERPRETATION

Postoperative pneumonia after hip surgery in children with a neurological CCC is associated with longer LOS, readmissions, and higher costs. Children undergoing pelvic osteotomies and who have multimorbidity need additional clinical support to prevent postoperative pneumonia and decrease resource utilization.

WHAT THIS PAPER ADDS

Pneumonia is a major postoperative complication in children with neurological complex chronic conditions (CCC). Forty-two (1.6%) children with neurological CCC developed pneumonia after hip surgery. Length of stay, readmissions, and costs were significantly higher in the group with pneumonia. Variability in pneumonia rates existed across hospitals. Predictors of developing pneumonia include osteotomy type and number of CCC.

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.

Gastro-oesophageal reflux disease in children with neurological impairment: a retrospective cohort study

OBJECTIVES

To determine the incidence and prevalence of gastro-oesophageal reflux disease (GERD) diagnosis and treatment in children with neurological impairment (NI) along with relationship to key variables.

DESIGN

This is a population-based retrospective cohort study.

SETTING

This study takes place in Alberta, Canada.

PATIENTS

Children with NI were identified by hospital-based International Classification of Diseases (ICD) codes from 2006 to 2018.

MAIN OUTCOME MEASURES

Incidence and prevalence of a GERD diagnosis identified by: (1) hospital-based ICD-10 codes; (2) specialist claims; (3) dispensation of acid-suppressing medication (ASM). Age, gender, complex chronic conditions (CCC) and technology assistance were covariates.

RESULTS

Among 10 309 children with NI, 2772 (26.9%) met the GERD definition. The unadjusted incidence rate was 52.1 per 1000 person-years (50.2-54.1). Increasing numbers of CCCs were associated with a higher risk of GERD. The HR for GERD associated with a gastrostomy tube was 4.56 (95% CI 4.15 to 5.00). Overall, 2486 (24.1%) of the children were treated with ASMs of which 1535 (61.7%) met no other GERD criteria. The incidence rate was 16.9 dispensations per year (95% CI 16.73 to 17.07). The prevalence of gastrojejunostomy tubes was 1.1% (n=121), surgical jejunostomy tubes was 0.7% (n=79) and fundoplication was 3.4% (n=351).

CONCLUSIONS

The incidence of GERD in children with NI greatly exceeds that of the general paediatric population. Similarly, incidence rate of medication dispensations was closer to the rates seen in adults particularly in children with multiple CCCs and gastrostomy tubes. Further research is needed to determine the appropriate use of ASMs balancing the potential for adverse effects in this population.

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.

Variation in Bacterial Respiratory Culture Results in Children With Neurologic Impairment

OBJECTIVES

To examine bacterial respiratory cultures in children with neurologic impairment (NI) (eg, cerebral palsy), both with and without tracheostomies, who were hospitalized with acute respiratory infections (ARIs) (eg, pneumonia) and to compare culture results across hospitals and age groups.

METHODS

This multicenter retrospective cohort study included ARI hospitalizations for children aged 1 to 18 years with NI between 2007 and 2012 who had a bacterial respiratory culture obtained within 2 days of admission. Data from 5 children's hospitals in the Pediatric Health Information System Plus database were used. Organisms consistent with oral flora and nonspeciated organisms were omitted from analysis. The prevalence of positive respiratory culture results and the prevalence of organisms identified were compared across hospitals and age groups and in subanalyses of children with and without tracheostomies by using generalized estimating equations to account for within-patient clustering.

RESULTS

Of 4900 hospitalizations, 693 from 485 children had bacterial respiratory cultures obtained. Of these, 54.5% had positive results, although this varied across hospitals (range 18.6%-83.2%; P < .001). Pseudomonas aeruginosa and Staphylococcus aureus were the most commonly identified organisms across hospitals and age groups and in patients with and without tracheostomies. Large variation in growth prevalence was identified across hospitals but not age groups.

CONCLUSIONS

The bacteriology of ARI in hospitalized children with NI differs from that of otherwise healthy children. Significant variation in prevalence of positive bacterial respiratory culture results and organism growth were observed across hospitals, which may be secondary to local environmental factors and microbiology reporting practices.

Gastric Flora in Gastrostomy Fed Children with Neurological Impairment on Antacid Medication

This prospective cohort study aimed to: (1) describe types, concentrations and sensitivity profiles of bacteria found in gastric aspirates of neurologically impaired children; (2) compare flora between outpatients and those admitted with aspiration pneumonia; and (3) examine predictors of bacterial colonization. Gastric aspirates from gastrostomy fed, neurologically impaired children on antacid medication were measured for pH and sent for microbiological testing. The outpatient arm included 26 children at their baseline; the inpatient arm included 31 children with a clinical diagnosis of aspiration pneumonia. Descriptive statistics summarized the ecology and resistance patterns of microbial flora. Predictors of total bacterial colonization were explored with linear regression. High concentrations of potentially pathogenic fecal-type bacteria were detected in 50/57 (88%) gastric aspirates. pH was found to be the only predictor of bacterial growth; children with gastric pH ≥ 4 had significantly higher concentrations of aerobic growth, while those with no bacterial growth had a pH < 4. Further studies to evaluate optimal gastric pH, the role of gastric bacteria in causing aspiration pneumonia, and the optimal empiric therapy for aspiration pneumonia are recommended.

Discharge Before Return to Respiratory Baseline in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are commonly hospitalized with acute respiratory infections (ARI). These children frequently require respiratory support at baseline and are often discharged before return to respiratory baseline.

OBJECTIVE

To determine if discharge before return to respiratory baseline is associated with reutilization among children with NI hospitalized with ARI.

METHODS

This single-center retrospective cohort study included children with NI aged 1 to 18 years hospitalized with ARI who required increased respiratory support between January 2010 and September 2015. The primary exposure was discharge before return to respiratory baseline. The primary outcome was 30-day hospital reutilization. A generalized estimating equation was used to examine the association between exposure and outcome while accounting for within-patient clustering and patient-level clinical complexity and illness severity.

RESULTS

In the 632 hospitalizations experienced by 366 children, children were discharged before return to respiratory baseline in 30.4% of hospitalizations. Compared with those hospitalizations in which children were discharged at baseline, hospitalizations with a discharge before return to respiratory baseline were more likely to be for privately insured, technology-dependent children with respiratory comorbidities. Compared with discharges at respiratory baseline, discharges with increased respiratory support had no difference in 30-day reutilization (32.8% vs 31.8%; P = .81; adjusted OR 0.80, 95% CI 0.51-1.26).

CONCLUSIONS

Among children with NI hospitalized with ARI, discharge before return to respiratory baseline was common, but it was not associated with hospital reutilization. Return to respiratory baseline may not be a necessary component of discharge criteria in this population.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

Survival and Health Care Use After Feeding Tube Placement in Children With Neurologic Impairment

BACKGROUND AND OBJECTIVES

Children with neurologic impairment (NI) often undergo feeding tube placement for undernutrition or aspiration. We evaluated survival and acute health care use after tube placement in this population.

METHODS

This is a population-based exposure-crossover study for which we use linked administrative data from Ontario, Canada. We identified children aged 13 months to 17 years with a diagnosis of NI undergoing primary gastrostomy or gastrojejunostomy tube placement between 1993 and 2015. We determined survival time from procedure until date of death or last clinical encounter and calculated mean weekly rates of unplanned hospital days overall and for reflux-related diagnoses, emergency department visits, and outpatient visits. Rate ratios were estimated from negative binomial generalized estimating equation models adjusting for time and age.

RESULTS

Two-year survival after feeding tube placement was 87.4% (95% confidence interval [CI]: 85.2%-89.4%) and 5-year survival was 75.8% (95% CI: 72.8%-78.4%). The adjusted rate ratio comparing weekly rates of unplanned hospital days during the 2 years after versus before tube placement was 0.92 (95% CI: 0.57-1.48). Similarly, rates of reflux-related hospital days, emergency department visits, and outpatient visits were unchanged. Unplanned hospital days were stable within subgroups, although rates across subgroups varied.

CONCLUSIONS

Mortality is high among children with NI after feeding tube placement. However, the stability of health care use before and after the procedure suggests that the high mortality may reflect underlying fragility rather than increased risk from nonoral feeding. Further research to inform risk stratification and prognostic accuracy is needed.

Effectiveness of an early switch from intravenous to oral antimicrobial therapy for lower respiratory tract infection in patients with severe motor intellectual disabilities

An early switch from intravenous to oral antimicrobial therapy is useful for reducing the duration of the hospitalization in adult patients with community acquired-pneumonia, whereas the efficacy of switch therapy for pediatric patients with community acquired (CA)-lower respiratory tract infection (LRTI) is uncertain. The aim of this study is to investigate the efficacy of switch therapy for LRTI in patients with severe motor intellectual disabilities (SMID). This retrospective study was performed on 92 patients with SMID who were admitted to the Department of Pediatrics at the Hospital of University of Occupational and Environmental Health, Japan from April 1, 2010 to March 31, 2017 for the suspicion of bacterial LRTI and were initially treated with an intravenous antimicrobial agent. Clinical outcomes were compared between patients with switch therapy (Switch therapy group) and conventional intravenous antimicrobial therapy (No switch therapy group). Thirteen and 79 in patients with SMID belonged to Switch thrapy group and No switch therapy group, respectively. Length of hospital stay in Switch therapy group was significantly shorter than that in No switch therapy group (P = 0.002). In the patients undergoing switch therapy, there was no patient who required re-treatment and/or re-hospitalization. Switch therapy for LRTI was useful for the reduction of length of hospital stay without increasing risk of re-treatment and re-hospitalization in patients with SMID.

Community-Acquired Pneumonia Hospitalization among Children with Neurologic Disorders

OBJECTIVE

To describe and compare the clinical characteristics, outcomes, and etiology of pneumonia among children hospitalized with community-acquired pneumonia (CAP) with neurologic disorders, non-neurologic underlying conditions, and no underlying conditions.

STUDY DESIGN

Children <18 years old hospitalized with clinical and radiographic CAP were enrolled at 3 US children's hospitals. Neurologic disorders included cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities. We compared the epidemiology, etiology, and clinical outcomes of CAP in children with neurologic disorders with those with non-neurologic underlying conditions, and those with no underlying conditions using bivariate, age-stratified, and multivariate logistic regression analyses.

RESULTS

From January 2010-June 2012, 2358 children with radiographically confirmed CAP were enrolled; 280 (11.9%) had a neurologic disorder (52.1% of these individuals also had non-neurologic underlying conditions), 934 (39.6%) had non-neurologic underlying conditions only, and 1144 (48.5%) had no underlying conditions. Children with neurologic disorders were older and more likely to require intensive care unit (ICU) admission than children with non-neurologic underlying conditions and children with no underlying conditions; similar proportions were mechanically ventilated. In age-stratified analysis, children with neurologic disorders were less likely to have a pathogen detected than children with non-neurologic underlying conditions. In multivariate analysis, having a neurologic disorder was associated with ICU admission for children ≥2 years of age.

CONCLUSIONS

Children with neurologic disorders hospitalized with CAP were less likely to have a pathogen detected and more likely to be admitted to the ICU than children without neurologic disorders.

Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment

BACKGROUND AND OBJECTIVE

Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia.

METHODS

A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children's hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics.

RESULTS

In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspiration pneumonia (34.0% vs 15.2%, adjusted odds ratio [aOR] 1.2 (95% confidence interval [CI] 1.1-1.3). Children with aspiration pneumonia had significantly longer length of stay (median 5 vs 3 days; ratio of means 1.2; 95% CI 1.2-1.3); more ICU transfers (4.3% vs 1.5%; aOR 1.4; 95% CI 1.1-1.9); greater hospitalization costs (median $11 594 vs $5162; ratio of means 1.2; 95% CI 1.2-1.3); and more 30-day readmissions (17.4% vs 6.8%; aOR 1.3; 95% CI 1.2-1.5).

CONCLUSIONS

Hospitalized children with NI diagnosed with aspiration pneumonia have more complications and use more hospital resources than when diagnosed with nonaspiration pneumonia. Additional investigation is needed to understand the reasons for these differences.

Shared decision-making about assistive technology for the child with severe neurologic impairment

Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.