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Gastroesophageal Reflux and the Neurologically Impaired Patient

  • Efstratios Saliakellis
  • Nikhil Thapar
Chapter

Abstract

Gastroesophageal reflux (GER) and its associated complications (gastroesophageal reflux disease—GERD) are very common in children with neurological impairment (NI) and correlate with the severity of neurodisability. A number of causative mechanisms underlie GERD in this population, many of which are inherent to the neurodisability and irreversible. Diagnosis is often difficult and compounded by a limited ability of NI children to communicate their symptoms, variable presentation and poor correlation with objective testing. Unfortunately, as a result, management is often misdirected and/or suboptimal. Overall, a high index of suspicion is needed for GERD when managing children with NI. A wide range of treatments are available for managing GER/GERD in this population of children, although the mainstay remains pharmacological therapy, namely, PPIs. A systematic approach is advised starting at simpler ‘conservative’ treatments through dietary manipulation, pharmacotherapy to surgical interventions. At each step there should be careful consideration of the benefits and risks and carers of NI children appropriately counselled about these. There is evidence to suggest that although there is a place for pharmacotherapy, consideration should also be given to diet both in terms of type and method of administration. In this respect there is emerging benefit for the use of post-pyloric feeding even as an alternative to surgery. Surgery, namely, anti-reflux procedures, should be considered the last resort although it appears to have a clear benefit in a highly selective group of NI children especially those with severe disability who have failed medical therapy. Overall, although there have been significant strides into understanding the management of NI children suffering problematic GER, there is a clear need for further robust studies in this challenging group.

Keywords

Gastroesophageal reflux Gastroesophageal reflux disease Neurologically impaired Children Cerebral palsy 

References

  1. 1.
    Del Giudice E, Staiano A, Capano G, et al. Gastrointestinal manifestations in children with cerebral palsy. Brain Dev. 1999;21:307–11.CrossRefPubMedGoogle Scholar
  2. 2.
    Reyes AL, Cash AJ, Green SH, et al. Gastrooesophageal reflux in children with cerebral palsy. Child Care Health Dev. 1993;19:109–18.CrossRefPubMedGoogle Scholar
  3. 3.
    Sondheimer JM, Morris BA. Gastroesophageal reflux among severely retarded children. J Pediatr. 1979;94:710–4.CrossRefPubMedGoogle Scholar
  4. 4.
    Ravelli AM, Milla PJ. Vomiting and gastroesophageal motor activity in children with disorders of the central nervous system. J Pediatr Gastroenterol Nutr. 1998;26:56–63.CrossRefPubMedGoogle Scholar
  5. 5.
    Wadie GM, Lobe TE. Gastroesophageal reflux disease in neurologically impaired children: the role of the gastrostomy tube. Semin Laparosc Surg. 2002;9:180–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. Dev Disabil Res Rev. 2008;14:128–36.CrossRefPubMedGoogle Scholar
  7. 7.
    Bohmer CJ, Klinkenberg-Knol EC, Niezen-de Boer RC, et al. The prevalence of gastro-oesophageal reflux disease based on non-specific symptoms in institutionalized, intellectually disabled individuals. Eur J Gastroenterol Hepatol. 1997;9:187–90.CrossRefPubMedGoogle Scholar
  8. 8.
    Wesley JR, Coran AG, Sarahan TM, et al. The need for evaluation of gastroesophageal reflux in brain-damaged children referred for feeding gastrostomy. J Pediatr Surg. 1981;16:866–71.CrossRefPubMedGoogle Scholar
  9. 9.
    de Veer AJ, Bos JT, Niezen-de Boer RC, et al. Symptoms of gastroesophageal reflux disease in severely mentally retarded people: a systematic review. BMC Gastroenterol. 2008;8:23.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gangil A, Patwari AK, Bajaj P, et al. Gastroesophageal reflux disease in children with cerebral palsy. Indian Pediatr. 2001;38:766–70.PubMedGoogle Scholar
  11. 11.
    Bohmer CJ, Niezen-de Boer MC, Klinkenberg-Knol EC, et al. Gastro-oesophageal reflux disease in institutionalised intellectually disabled individuals. Neth J Med. 1997;51:134–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Quitadamo P, Thapar N, Staiano A, et al. Gastrointestinal and nutritional problems in neurologically impaired children. Eur J Paediatr Neurol. 2016;20:810–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Kawahara H, Nakajima K, Yagi M, et al. Mechanisms responsible for recurrent gastroesophageal reflux in neurologically impaired children who underwent laparoscopic Nissen fundoplication. Surg Endosc. 2002;16:767–71.CrossRefPubMedGoogle Scholar
  14. 14.
    Pensabene L, Miele E, Del Giudice E, et al. Mechanisms of gastroesophageal reflux in children with sequelae of birth asphyxia. Brain Dev. 2008;30:563–71.CrossRefPubMedGoogle Scholar
  15. 15.
    Miki K, Harada T, Kozaiwa K, et al. Antroduodenal motor function and gastro-oesophageal reflux in neurologically impaired children, adolescents and young adults. Eur J Pediatr. 1998;157:695–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Dodds WJ, Dent J, Hogan WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med. 1982;307:1547–52.CrossRefPubMedGoogle Scholar
  17. 17.
    Sloan S, Rademaker AW, Kahrilas PJ. Determinants of gastroesophageal junction incompetence: hiatal hernia, lower esophageal sphincter, or both? Ann Intern Med. 1992;117:977–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Staiano A, Cucchiara S, Del Giudice E, et al. Disorders of oesophageal motility in children with psychomotor retardation and gastro-oesophageal reflux. Eur J Pediatr. 1991;150:638–41.CrossRefPubMedGoogle Scholar
  19. 19.
    Gustafsson PM, Tibbling L. Gastro-oesophageal reflux and oesophageal dysfunction in children and adolescents with brain damage. Acta Paediatr. 1994;83:1081–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Kawahara H, Tazuke Y, Soh H, et al. Causal relationship between delayed gastric emptying and gastroesophageal reflux in patients with neurological impairment. Pediatr Surg Int. 2015;31:917–23.CrossRefPubMedGoogle Scholar
  21. 21.
    Knatten CK, Avitsland TL, Medhus AW, et al. Gastric emptying in children with gastroesophageal reflux and in healthy children. J Pediatr Surg. 2013;48:1856–61.CrossRefPubMedGoogle Scholar
  22. 22.
    Stevenson RD, Conaway M, Chumlea WC, et al. Growth and health in children with moderate-to-severe cerebral palsy. Pediatrics. 2006;118:1010–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Fukahori S, Asagiri K, Ishii S, et al. Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH-multichannel intraluminal impedance measurements. Pediatr Surg Int. 2013;29:545–51.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Mauritz FA, van Herwaarden-Lindeboom MY, Stomp W, et al. The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review. J Gastrointest Surg. 2011;15:1872–8.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Spiroglou K, Xinias I, Karatzas N, et al. Gastric emptying in children with cerebral palsy and gastroesophageal reflux. Pediatr Neurol. 2004;31:177–82.CrossRefPubMedGoogle Scholar
  26. 26.
    Okada T, Sasaki F, Asaka M, et al. Delay of gastric emptying measured by 13C-acetate breath test in neurologically impaired children with gastroesophageal reflux. Eur J Pediatr Surg. 2005;15:77–81.CrossRefPubMedGoogle Scholar
  27. 27.
    Wenzl TG, Benninga MA, Loots CM, et al. Indications, methodology, and interpretation of combined esophageal impedance-pH monitoring in children: ESPGHAN EURO-PIG standard protocol. J Pediatr Gastroenterol Nutr. 2012;55:230–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Inge TH, Carmeci C, Ohara LJ, et al. Outcome of Nissen fundoplication using intraoperative manometry in children. J Pediatr Surg. 1998;33:1614–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Komura M, Kanamori Y, Tanaka Y, et al. Mosapride for gastroesophageal reflux disease in neurologically impaired patients. Pediatr Int. 2016;59(3):347–51.CrossRefPubMedGoogle Scholar
  30. 30.
    Kawai M, Kawahara H, Hirayama S, et al. Effect of baclofen on emesis and 24-hour esophageal pH in neurologically impaired children with gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr. 2004;38:317–23.CrossRefPubMedGoogle Scholar
  31. 31.
    Erkin G, Culha C, Ozel S, et al. Feeding and gastrointestinal problems in children with cerebral palsy. Int J Rehabil Res. 2010;33:218–24.CrossRefPubMedGoogle Scholar
  32. 32.
    Waterman ET, Koltai PJ, Downey JC, et al. Swallowing disorders in a population of children with cerebral palsy. Int J Pediatr Otorhinolaryngol. 1992;24:63–71.CrossRefPubMedGoogle Scholar
  33. 33.
    Benfer KA, Weir KA, Bell KL, et al. Clinical signs suggestive of pharyngeal dysphagia in preschool children with cerebral palsy. Res Dev Disabil. 2015;38:192–201.CrossRefPubMedGoogle Scholar
  34. 34.
    Vandenplas Y, De Schepper J, Verheyden S, et al. A preliminary report on the efficacy of the Multicare AR-Bed in 3-week-3-month-old infants on regurgitation, associated symptoms and acid reflux. Arch Dis Child. 2010;95:26–30.CrossRefPubMedGoogle Scholar
  35. 35.
    Loots C, Smits M, Omari T, et al. Effect of lateral positioning on gastroesophageal reflux (GER) and underlying mechanisms in GER disease (GERD) patients and healthy controls. Neurogastroenterol Motil. 2013;25:222–9, e161-2.CrossRefPubMedGoogle Scholar
  36. 36.
    Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. 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). J Pediatr Gastroenterol Nutr. 2009;49:498–547.CrossRefPubMedGoogle Scholar
  37. 37.
    Turk H, Hauser B, Brecelj J, et al. Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children. World J Pediatr. 2013;9:36–41.CrossRefPubMedGoogle Scholar
  38. 38.
    Cheung KM, Tse PW, Ko CH, et al. Clinical efficacy of proton pump inhibitor therapy in neurologically impaired children with gastroesophageal reflux: prospective study. Hong Kong Med J. 2001;7:356–9.PubMedGoogle Scholar
  39. 39.
    Canani RB, Cirillo P, Roggero P, et al. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Pediatrics. 2006;117:e817–20.CrossRefPubMedGoogle Scholar
  40. 40.
    Safe M, Chan WH, Leach ST, et al. Widespread use of gastric acid inhibitors in infants: are they needed? Are they safe? World J Gastrointest Pharmacol Ther. 2016;7:531–9.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Bozkurt M, Tutuncuoglu S, Serdaroglu G, et al. Gastroesophageal reflux in children with cerebral palsy: efficacy of cisapride. J Child Neurol. 2004;19:973–6.PubMedGoogle Scholar
  42. 42.
    Brueton MJ, Clarke GS, Sandhu BK. The effects of cisapride on gastro-oesophageal reflux in children with and without neurological disorders. Dev Med Child Neurol. 1990;32:629–32.CrossRefPubMedGoogle Scholar
  43. 43.
    Maclennan S, Augood C, Cash-Gibson L, et al. Cisapride treatment for gastro-oesophageal reflux in children. Cochrane Database Syst Rev. 2010;(4):CD002300.Google Scholar
  44. 44.
    Horwood JF, Calvert W, Mullassery D, et al. Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children–a single centre experience. J Pediatr Surg. 2015;50:275–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Campanozzi A, Capano G, Miele E, et al. Impact of malnutrition on gastrointestinal disorders and gross motor abilities in children with cerebral palsy. Brain Dev. 2007;29:25–9.Google Scholar
  46. 46.
    Miyazawa R, Tomomasa T, Kaneko H, et al. Effects of pectin liquid on gastroesophageal reflux disease in children with cerebral palsy. BMC Gastroenterol. 2008;8:11.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Miele E, Staiano A, Tozzi A, et al. Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis. J Pediatr Gastroenterol Nutr. 2002;35:314–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Khoshoo V, Zembo M, King A, et al. Incidence of gastroesophageal reflux with whey- and casein-based formulas in infants and in children with severe neurological impairment. J Pediatr Gastroenterol Nutr. 1996;22:48–55.CrossRefPubMedGoogle Scholar
  49. 49.
    Savage K, Kritas S, Schwarzer A, et al. Whey- vs casein-based enteral formula and gastrointestinal function in children with cerebral palsy. JPEN J Parenter Enteral Nutr. 2012;36:118S–23S.CrossRefPubMedGoogle Scholar
  50. 50.
    Marchand V, Motil KJ, Nutrition NCo. Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:123–35.CrossRefPubMedGoogle Scholar
  51. 51.
    Friedman JN, Ahmed S, Connolly B, et al. Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children. Pediatrics. 2004;114:458–61.CrossRefPubMedGoogle Scholar
  52. 52.
    Wales PW, Diamond IR, Dutta S, et al. Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux. J Pediatr Surg. 2002;37:407–12.CrossRefPubMedGoogle Scholar
  53. 53.
    Campwala I, Perrone E, Yanni G, et al. Complications of gastrojejunal feeding tubes in children. J Surg Res. 2015;199:67–71.CrossRefPubMedGoogle Scholar
  54. 54.
    Livingston MH, Shawyer AC, Rosenbaum PL, et al. Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: a systematic review and meta-analysis. J Pediatr Surg. 2015;50:707–14.CrossRefPubMedGoogle Scholar
  55. 55.
    Srivastava R, Berry JG, Hall M, et al. Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study. BMJ. 2009;339:b4411.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Srivastava R, Downey EC, O’Gorman M, et al. Impact of fundoplication versus gastrojejunal feeding tubes on mortality and in preventing aspiration pneumonia in young children with neurologic impairment who have gastroesophageal reflux disease. Pediatrics. 2009;123:338–45.CrossRefPubMedGoogle Scholar
  57. 57.
    Spitz L, McLeod E. Gastroesophageal reflux. Semin Pediatr Surg. 2003;12:237–40.CrossRefPubMedGoogle Scholar
  58. 58.
    Fukahori S, Yagi M, Ishii S, et al. Laparoscopic Nissen fundoplication mainly reduces the volume of acid reflux and potentially improves mucosal integrity up to the middle esophagus in neurologically impaired children detected by esophageal combined pH-multichannel intraluminal impedance measurements. J Pediatr Surg. 2016;51:1283–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Miyano G, Yamoto M, Morita K, et al. Laparoscopic Toupet fundoplication for gastroesophageal reflux: a series of 131 neurologically impaired pediatric cases at a single children’s hospital. Pediatr Surg Int. 2015;31:925–9.CrossRefPubMedGoogle Scholar
  60. 60.
    O’Loughlin EV, Somerville H, Shun A, et al. Antireflux surgery in children with neurological impairment: caregiver perceptions and complications. J Pediatr Gastroenterol Nutr. 2013;56:46–50.CrossRefPubMedGoogle Scholar
  61. 61.
    Kawahara H, Okuyama H, Kubota A, et al. Can laparoscopic antireflux surgery improve the quality of life in children with neurologic and neuromuscular handicaps? J Pediatr Surg. 2004;39:1761–4.CrossRefPubMedGoogle Scholar
  62. 62.
    Wockenforth R, Gillespie CS, Jaffray B. Survival of children following Nissen fundoplication. Br J Surg. 2011;98(5):680.CrossRefPubMedGoogle Scholar
  63. 63.
    Pearl RH, Robie DK, Ein SH, et al. Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children. J Pediatr Surg. 1990;25:1169–73.CrossRefPubMedGoogle Scholar
  64. 64.
    Martin K, Deshaies C, Emil S. Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature. Can J Gastroenterol Hepatol. 2014;28:97–102.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Ngerncham M, Barnhart DC, Haricharan RN, et al. Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg. 2007;42:1478–85.CrossRefPubMedGoogle Scholar
  66. 66.
    Toporowska-Kowalska E, Gebora-Kowalska B, Jablonski J, et al. Influence of percutaneous endoscopic gastrostomy on gastro-oesophageal reflux evaluated by multiple intraluminal impedance in children with neurological impairment. Dev Med Child Neurol. 2011;53:938–43.CrossRefPubMedGoogle Scholar
  67. 67.
    Ponsky TA, Gasior AC, Parry J, et al. Need for subsequent fundoplication after gastrostomy based on patient characteristics. J Surg Res. 2013;179:1–4.CrossRefPubMedGoogle Scholar
  68. 68.
    Kawahara H, Mitani Y, Nose K, et al. Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired? J Pediatr Surg. 2010;45:2373–6.CrossRefPubMedGoogle Scholar
  69. 69.
    Kakade M, Coyle D, McDowell DT, et al. Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children. Pediatr Surg Int. 2015;31:557–62.CrossRefPubMedGoogle Scholar
  70. 70.
    Heuschkel RB, Gottrand F, Devarajan K, et al. ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents. J Pediatr Gastroenterol Nutr. 2015;60:131–41.CrossRefPubMedGoogle Scholar
  71. 71.
    Gatti C, di Abriola GF, Villa M, et al. Esophagogastric dissociation versus fundoplication: which is best for severely neurologically impaired children? J Pediatr Surg. 2001;36:677–80.CrossRefPubMedGoogle Scholar
  72. 72.
    Goyal A, Khalil B, Choo K, et al. Esophagogastric dissociation in the neurologically impaired: an alternative to fundoplication? J Pediatr Surg. 2005;40:915–8. discussion 918-9CrossRefPubMedGoogle Scholar
  73. 73.
    Morabito A, Lall A, Lo Piccolo R, et al. Total esophagogastric dissociation: 10 years’ review. J Pediatr Surg. 2006;41:919–22.CrossRefPubMedGoogle Scholar
  74. 74.
    Peters RT, Goh YL, Veitch JM, et al. Morbidity and mortality in total esophagogastric dissociation: a systematic review. J Pediatr Surg. 2013;48:707–12.CrossRefPubMedGoogle Scholar
  75. 75.
    Lansdale N, McNiff M, Morecroft J, et al. Long-term and ‘patient-reported’ outcomes of total esophagogastric dissociation versus laparoscopic fundoplication for gastroesophageal reflux disease in the severely neurodisabled child. J Pediatr Surg. 2015;50:1828–32.CrossRefPubMedGoogle Scholar
  76. 76.
    Gottrand M, Michaud L, Guimber D, et al. Barrett esophagus and esophagojejunal anastomotic stenosis as complications of esophagogastric disconnection in children with esophageal atresia. J Pediatr Gastroenterol Nutr. 2013;57:93–5.CrossRefPubMedGoogle Scholar
  77. 77.
    Lall A, Morabito A, Dall'Oglio L, et al. Total oesophagogastric dissociation: experience in 2 centres. J Pediatr Surg. 2006;41:342–6.CrossRefPubMedGoogle Scholar
  78. 78.
    Madre C, Serhal L, Michaud L, et al. Prolonged enteral feeding is often required to avoid long-term nutritional and metabolic complications after esophagogastric dissociation. J Pediatr Gastroenterol Nutr. 2010;50:280–6.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Great Ormond Street NHS Foundation TrustLondonUK
  2. 2.UCL Great Ormond Street Institute of Child HealthLondonUK

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