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Aim: Percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG) are common procedures in children with neurological impairment (NI) with swallowing difficulties. Pulmonary aspirations are a major concern and performing concomitant or delayed fundoplication is still controversial, especially among these patients. The aim of our study was to review our experience with fundoplication performed concomitantly with gastrostomy or later and to evaluate patient outcomes. Methods: This is a retrospective, cohort study including all paediatric patients who underwent SG or PEG with or without Nissen fundoplication at Schneider Children's Medical Center of Israel between the years 2007 and 2018. Patients' clinical and surgical data were recorded and analysed. Results: Between 2007 and 2018, 345 patients underwent SG or PEG. Of these, 89 patients underwent fundoplication. Of the patients who underwent PEG/SG, 158 (45.8%) were neurologically impaired. Most of the patients who underwent fundoplication (n = 69, 77.5%) were NI patients (P = 0.0001). NI patients with refractory seizures showed almost no improvement in terms of relief of gastro‐oesophageal reflux disease symptoms following fundoplication (P = 0.0001) compared to NI patients without refractory seizures. Conclusion: Our findings suggest that in NI patients a concomitant fundoplication is not mandatory and is not efficacious in preventing gastro‐oesophageal reflux disease in patients with refractory seizures. [ABSTRACT FROM AUTHOR]

Among the various cochlear implant systems approved by the Food and Drug Administration, current labeling for pediatric usage encompasses (1) bilateral profound bilateral sensorineural hearing loss in children aged 9 to 24 months and bilateral severe to profound sensorineural hearing loss in children older than 2 years; (2) use of appropriately fitted hearing aids for 3 months (this can be waived if there is evidence of ossification); and (3) demonstration of limited progress with auditory, speech, and language development. Pediatric guidelines require children to have significantly worse speech understanding before qualifying for cochlear implantation. The early years of life have been shown to be critical for speech and language development, and auditory deprivation is especially detrimental during this crucial time. Level of evidence: 2. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate health-related quality-of-life (HRQoL) measures in noncommunicative, neurologically impaired, developmentally delayed (NCNIDD) children compared to normally developing children (ND) who undergo cochlear implantation (CI). Study Design: Cross-sectional survey of parents of NCNIDD and ND children who underwent CI. Setting: Two tertiary care medical centers. Methods: Questions comprising the Children With Cochlear Implants: Parental Perspectives survey were used in analysis. Average responses were calculated within 8 domains (communication, general functioning, self-reliance, well-being and happiness, social relationships, education, effects of implantation, and support the child). Groups were compared using Wilcoxon rank-sum test. Impact of individual and collective socioeconomic/family covariates was assessed using analysis of variance. Results: Surveys were returned from 17 of 42 (40%) patients with NCNIDD and 35 of 131 (27%) patients with ND. There were no statistically significant differences between groups in survey response rate, age, sex, age at implantation, current age, or duration of implant use. Overall, parents of children with ND responded more favorably in all domains vs children with NCNIDD. Parents of children with NCNIDD answered neutrally or favorably in all domains, except "support the child" and "self-reliance" domains. Differences between groups in mean domain scores, univariably and almost universally when adjusting for socioeconomic and family variables individually and collectively, were statistically significant. Conclusions: This study suggests that HRQoL benefits of CI are perceived in most domains by parents of children with NCNIDD, albeit less strongly than children with ND. A survey sensitive to challenges of children with NCNIDD may better capture benefits that may not be apparent in this study. [ABSTRACT FROM AUTHOR]

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children.Methods: Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared.Results: There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods.Conclusion: Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term. [ABSTRACT FROM AUTHOR]

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

Background: Insulin resistance (IR) plays a key role in the pathogenesis of type 2 diabetes (T2D). In neurologically impaired (NI) children unfavorable cardio-metabolic risk profile with high prevalence of IR has been reported. We evaluated the prevalence of T2D in NI children and adolescents, in order to define if a dedicated glucose monitoring may be recommended in these subjects.Methods: We retrospectively evaluated 63 patients (11.4 ± 4.0 years) with severe disabilities. Auxological parameters were recorded. Metabolic blood assays included fasting blood glucose (FBG), fasting insulin, triglycerides (TG). IR was detected with the homeostasis model assessment for insulin resistance (HOMA-IR > 97.5th percentile for age and sex) and triglyceride-glucose index (TyG index > 7.88). Elevated FBG was defined with values >100 mg/dl. T2D was defined according to American Diabetes Association criteria.Results: Impaired insulin sensitivity, pathological TyG index and elevated FBG were observed, respectively, in 41.3, 63.5, and 11.1% patients. T2D was diagnosed in 3.2% asymptomatic patients. The prevalence of diabetes was higher in pre-pubertal compared to pubertal subjects (p = 0.03).Conclusions: T2D in NI children and adolescents without obesity could represent a new emerging entity. IR and/or surrogate markers of IR index may be useful for the primary screening of this at-risk disabled population so as to prevent diabetes.

Background: Insulin resistance (IR) plays a key role in the pathogenesis of type 2 diabetes (T2D). In neurologically impaired (NI) children unfavorable cardio-metabolic risk profile with high prevalence of IR has been reported. We evaluated the prevalence of T2D in NI children and adolescents, in order to define if a dedicated glucose monitoring may be recommended in these subjects. Methods: We retrospectively evaluated 63 patients (11.4 ± 4.0 years) with severe disabilities. Auxological parameters were recorded. Metabolic blood assays included fasting blood glucose (FBG), fasting insulin, triglycerides (TG). IR was detected with the homeostasis model assessment for insulin resistance (HOMA-IR > 97.5th percentile for age and sex) and triglyceride-glucose index (TyG index > 7.88). Elevated FBG was defined with values >100 mg/dl. T2D was defined according to American Diabetes Association criteria. Results: Impaired insulin sensitivity, pathological TyG index and elevated FBG were observed, respectively, in 41.3, 63.5, and 11.1% patients. T2D was diagnosed in 3.2% asymptomatic patients. The prevalence of diabetes was higher in pre-pubertal compared to pubertal subjects (p = 0.03). Conclusions: T2D in NI children and adolescents without obesity could represent a new emerging entity. IR and/or surrogate markers of IR index may be useful for the primary screening of this at-risk disabled population so as to prevent diabetes. [ABSTRACT FROM AUTHOR]

Total esophagogastric dissociation (TED) is used to treat gastroesophageal reflux (GER) after failed fundoplication in neurologically impaired patients. It is now performed for some otherwise healthy patients with severe GER. In this procedure, the gastrointestinal tract is reconstructed in a non-physiological way with a Roux-en-Y esophagojejunal anastomosis and jejuno-jejunostomy. Although TED eliminates almost all GER, some patients experience late complications. In this review, we investigated the long-term outcomes after TED to determine the best indications. In total, 147 neurologically impaired patients and 28 neurologically normal patients were identified. The total rate of complications requiring re-operation was 17.2% in neurologically impaired patients and 32.1% in normal patients, both higher than the rates associated with fundoplication. Although most authors added pyloroplasty when there was a concern of gastric emptying, this sometimes caused bile reflux. Nutritional and metabolic complications, including dumping syndrome and chronic digestive malabsorption, were also reported to occur after TED. TED is an option for the treatment of neurologically impaired patients with recurrent GER after fundoplication or who are at a high risk of recurrence of GER with fundoplication. However, neurologically normal patients who have the ability to obtain nutrition orally should consider options other than TED, as postoperative complications are frequent. [ABSTRACT FROM AUTHOR]

The discontinuation of life sustaining medical treatment (LSMT) in severely and permanently impaired neonates, especially artificial nutrition and hydration (ANH) is subject to uncertainty and controversy. Definitive clinical guidelines are lacking, clinical research is limited, ethical disagreement is commonplace, and while case and statutory law provide legal underpinning for the practice in defined circumstances, uncertainty in this realm likely influences clinical practice. We use the case of a neurologically devastated neonate to highlight and review these arenas, and show how, using available legal, ethical, and clinical standards and practice, the case of Baby O was resolved, and to underline the need for further research in neonatal palliative care. [ABSTRACT FROM AUTHOR]

Background The aim of the present study was to investigate whether the baseline impedance ( BI) value is a useful parameter to evaluate the condition of the esophageal mucosa in neurologically impaired ( NI) children undergoing multichannel intraluminal impedance pH measurements (pH/ MII). Methods The retrospective study included 55 NI patients ≤15 years. The patients were divided into acid gastroesophageal reflux disease ( GERD), non-acid GERD and GERD (−) groups. Furthermore, the patients in the acid GERD group were subdivided into erosive reflux disease ( ERD) and non-erosive reflux disease ( NERD) groups. pH/ MII parameters and BI values (Z1-6) were compared among three groups or between two groups, respectively. A Spearman's correlation analysis was used for the correlation analysis of pH/ MII parameters and BI values. A receiver operator characteristic curve analysis was used to evaluate the optimum cut-off values of BI to discriminate ERD patients. Key Results The BI values of the proximal and the distal channels in ERD group were significantly lower than those in NERD group. The BI values of the distal channels demonstrated significant negative correlations with acid exposure related pH/ MII parameters. The optimal cut off value of BI in the most distal channel was determined to be 1500 Ω. Conclusions & Inferences The present study suggested that NI children with reflux esophagitis were likely to suffer mucosal damage up to the proximal esophagus and cut-off BI values may help estimate the presence of reflux esophagitis. Baseline impedance is a potent parameter, reflecting the esophageal mucosal damage in NI children who have difficulty in undergoing endoscopic examinations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Rates of neurological impairment among extremely low birth weight children (ELBW [<1 kg]) have decreased since 2000; however, their functioning is unexamined. OBJECTIVE: To compare motor and cognitive functioning of ELBW children with neurological impairment, including cerebral palsy and severe hypotonia/hypertonia, between two periods: 1990 to 1999 (n=83) and 2000 to 2005 (n=34). METHODS: Measures of function at 20 months corrected age included the Mental and Psychomotor Developmental Indexes of the Bayley Scales of Infant Development and the Gross Motor Functional Classification System as primary outcomes and individual motor function items as secondary outcomes. RESULTS: Analysis failed to reveal significant differences for the primary outcomes, although during 2000 to 2005, sitting significantly improved in children with neurological impairment (P=0.003). CONCLUSION: Decreases in rates of neurological impairment among ELBW children have been accompanied by a suggestion of improved motor function, although cognitive function has not changed. [ABSTRACT FROM AUTHOR]

Every day, nurses face difficult clinical situations. Neurologically impaired patients can be physically challenging patients by the nature of the illness; however, these patients can present unique ethical challenges as well. Nurses caring for neurologically impaired patients may experience a high burden of moral distress. This article seeks to briefly review the development of the Western medical ethical landscape and to highlight the unique ethical conflicts of nursing neurologically impaired patients. [ABSTRACT FROM AUTHOR]

Children with underlying neurologic conditions or developmental delay may have undergone prior surgical therapy to improve quality of life. These patients may present to the emergency room with complications associated with these procedures or present requiring emergent or urgent surgical management of a new diagnosis. An understanding of the anatomic variation and known long-term complications of these devices is important for any surgeon who may be called to care for these patients. The goal of this article was to provide recommendations that will assist the general surgeon in the surgical management of children with neurologic impairment or developmental delay., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Chronic neurological disorders in children have significant effects on adult medical and social function. Transition from pediatric to adult services is a complex process. No objective data are available to inform physicians about the most effective approach. Nevertheless the most recommended approach is a joint pediatric/adult transition clinic. Malnutrition, either under or overnutrition, is a common condition among neurologically impaired children. Undernutrition is most prevalent, and its causes are diverse: insufficient caloric intake, excessive nutrient losses and abnormal energy metabolism. Malnutrition is associated with significant morbidity, while nutritional rehabilitation improves overall health as well as quality of life. It is not easy to determine which the nutritional needs in these patients are. Besides, they often present difficulties for oral feeding, mainly due to promoter dysfunction. Gastrointestinal symptoms, gastro esophageal reflux and constipation, as well as spasticity, scoliosis and joint deformities contribute to these difficulties. Because of that, an assessment of nutritional status should be performed periodically, and to assess efficacy and security of oral intake. If modifying oral diet we cannot confirm an adequate support, a nasogastric tube or a gastrostomy need to be considered. Often, a fundoplication is associated to the placement of a gastrostomy. Although the outcomes in a better nutritional status and quality of life are often obtained, it is not an easy decision for families. [ABSTRACT FROM AUTHOR]

Background: Gastroesophageal reflux disease (GERD) in patients with neurological impairment (NI) has not been fully studied before and after fundoplication procedure because their characteristics such as generalized gastrointestinal dysmotility, non-acid reflux, and the proximal reflux due to feeding of enteral nutrition via a nasogastric tube prevent their GERD from being detected by 24 h pH monitoring. The aim of this study was to elucidate whether multichannel impedance-pH measurement (pH/MII) is able to detect the subtypes of GERD and the differences in the reflux episodes of the severity of GERD, the ingestion pathway, and before and after fundoplication. The second aim was to determine whether a trial evaluation of dry swallows was able to be used to assess the esophageal motility of NI patients as an alternative examination. Patients and methods: The 24 h pH/MII was conducted on 20 NI children [15 were the patients before Nissen's fundoplication (BN), of whom, six were fed orally (FO) and nine were fed via nasogastric tube (NGT), and five were the patients after Nissen's fundoplication (AN)]. All reflux episodes were evaluated and compared between patients with pathological GERD (PG) and non-pathological GERD (NG) and between patients who had FO and NGT and patients between BN and AN. Dry swallows were conducted to evaluate the esophageal motility. The average bolus presence time (BPT) and total bolus transit time (TBTT) were compared between the PG and NG, FO and NGT, and the BN and AN subgroups. Results: A total of 1,064 reflux episodes were detected by pH/MII. Of those, 303 (28.5 %) were non-acid-related and 477 episodes reached the proximal esophagus. Of the 12 patients (57.1 %) showing pathological GERD, two cases (16.7 %) demonstrated predominantly weakly acidic PG. More than half of the reflux episodes of PG patients reached to the proximal esophagus. The numbers of total reflux and proximal reflux episodes in the PG were significantly higher than those in NG patients. The number of proximal reflux episodes in the FO group was significantly higher than that in the NGT groups, whereas NGT patients showed more non-acidic reflux episodes than FO patients. A trial evaluation of dry swallows demonstrated no significant differences in this study. Conclusion: The pH/MII was useful to detect the subtype of GERD in NI patients which could not be detected by 24 h pH monitoring. It can, therefore, be considered to have first priority for testing NI patients who are suspected to be suffering from GERD. [ABSTRACT FROM AUTHOR]

Abstract: Background: Gastrostomy tube placement is common in children. Many of the conditions associated with need for gastrostomy are also associated with gastroesophageal reflux. It is not clear how many patients without complicated reflux will subsequently require a fundoplication or which conditions increase this risk. Therefore, we performed a two-center review to determine the disease-specific propensity for fundoplication after gastrostomy tube placement. Methods: The data set was retrospectively collected from two centers from 2000 to 2008. All patients underwent gastrostomy tube placement without fundoplication owing to the surgeon''s discernment that fundoplication was not needed at the time. Pearson''s correlation was used to evaluate the influence of patient variables and operative approach against the subsequent need for fundoplication. Significance was defined as two-tailed P ≤ 0.01. Logistic regression analysis was used to evaluate independence. Results: A total of 684 patients underwent gastrostomy tube placement only, of which 124 were open, 282 laparoscopic, and 278 endoscopic (percutaneous endoscopic gastrostomy). The mean patient age was 2.9 years. Subsequent fundoplication was performed in 62 patients (9.1%). The mean interval to fundoplication was 20.7 months. Cerebral palsy and anoxic brain injury had the most significant correlation with subsequent fundoplication. These were also independent predictors. The laparoscopic approach had a negative correlation with the subsequent need for fundoplication. Conclusions: The low incidence of subsequent fundoplication in children who undergo gastrostomy tube placement justifies conservative use of fundoplication in the absence of complicated reflux. Those with cerebral palsy and anoxic brain injury appeared to have the greatest risk of the need for subsequent fundoplication. [Copyright &y& Elsevier]

Abstract: The clinical scenario of a neurologically impaired child with a prolonged history of gastroesophageal reflux disease that underwent open Roux-en-Y gastrojejunostomy with subsequent development of severe symptomatic bile reflux is reported. The presentation, evaluation, and surgical management by laparoscopic revision to a modified esophagogastric dissociation are discussed. [Copyright &y& Elsevier]

This prospective study investigated the therapy-induced changes in the quality of life (QoL) experienced by neurologically healthy and neurodevelopmentally delayed children and their parents after laparoscopic anterior 270° fundoplication (LAF). In this study, 40 patients (21 impaired) with a mean age of 7.8 years underwent LAF for gastroesophageal reflux disease (GERD) and were evaluated before surgery and then 3 and 6 months afterward using the Gastrointestinal Quality-of-Life Index (GIQLI) supplemented by conventional symptom markers. Growth, proton pump inhibitor use, and frequency of supraesophageal/respiratory symptoms improved significantly ( p < 0.001) as did feeding parameters ( p < 0.05). The global GIQLI score improved by 49 ± 21% ( p < 0.001). The greatest improvement occurred in the symptoms domain ( p < 0.001). However, positive alterations also were found in the dimensions of emotions (58%), social functions (37%) and physical functions (27%) ( p < 0.001). Comparison of the overall benefit did not show any differences between the subgroups of neurologically fit and impaired children. However, for the child-centered symptoms domain, the benefit increased stepwise with the degree of impairment. This was counterbalanced by an inverse relationship for the parent-centered emotions domain ( p < 0.05). Besides the known improvement in symptoms, LAF achieves a significant improvement in QoL for children and their parents. There is no overall difference in the benefit experienced by neurologically impaired and healthy children. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Delayed gastric emptying (DGE) as indicated by preoperative gastric emptying scan (GES) is one rationale for performing a gastric emptying procedure (GEP) at time of fundoplication for gastroesophageal reflux disease (GERD). However, the role of GES and GEP in the surgical management of GERD remains unclear. We examined the use of preoperative GES in fundoplication patients. Methods: Retrospective chart review of patients undergoing fundoplication from 2000 to 2005 in a single institution including patient demographics, operative procedure, and postoperative outcomes at 1-year follow-up was analyzed using χ 2 test. Results: Of 76 fundoplication patients, 39 (51%) had preoperative GES with 11 patients (28%) having DGE and 16 GEP performed. Developmentally delayed children were more likely to have GES. There were no significant differences in postoperative complications, length of hospital stay, or use of anti-GERD medications at 1 year between patients who had preoperative GES and those who did not. In the developmentally delayed group, there were no differences in outcomes between those with preoperative GES and those who did not. Conclusions: There were no differences in outcomes for GERD patients with or without preoperative GES or GEP postfundoplication. The use of GES in the management of GERD requires further evaluation. [Copyright &y& Elsevier]

Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastresophageal reflux (GER). In 1997, Bianchi proposed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. Little information exists about the best management for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. We present our experience in three adult patients with neurological impairment in whom TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed for permanent treatment of GER. [ABSTRACT FROM AUTHOR]

The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications. From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient’s outcome was assessed by symptom evaluation, technical examinations and a questionnaire. Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient’s parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score. The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients. [ABSTRACT FROM AUTHOR]

Rationale: Children with neurologic impairment often present with airway obstruction that may require intervention. No single method of airway intervention is universally appropriate and effective in this patient population. This study was performed to examine the effectiveness of using adenotonsillectomy and uvulopalatopharyngoplasty (UPPP) in resolving obstructive apnea (OA) in patients with neurologic impairment. Methods: A retrospective chart review of 15 patients with neurologic impairment and OA treated with adenotonsillectomy and UPPP between 1986 and 1998 at Children''s Hospital of Wisconsin (CHW) was performed. All patients in the series had their primary area of obstruction in the posterior oropharynx involving the soft palate, pharyngeal walls and base of tongue. Post-operative improvement following adenotonsillectomy and UPPP was examined. Measures of improvement were based primarily on recorded lowest oxygen saturations, but clinical parameters, flexible upper airway endoscopy and polysomnography were used as well. Results: Patient improvement was documented in 87% of patients treated with this modality. For the group, the mean lowest recorded oxygen saturation demonstrated a statistically significant improvement from 65% pre-operatively to 85% post-operatively (P=0.005). In long-term follow-up of these patients, 77% (10 of 13) of those showing initial improvement have done well and have required no further airway intervention. However, 23% of these patients demonstrated the need for further airway intervention during follow-up. Conclusions: Adenotonsillectomy with UPPP is worthy of consideration in certain neurologically impaired patients with moderate to severe OA, limited primarily to the posterior pharyngeal area. Initial improvement may not be permanent and close long-term follow-up of patients is imperative. [Copyright &y& Elsevier]

Malnutrition, either under- or overnutrition, is a common condition among neurologically impaired children. Energy needs are difficult to define in this heterogeneous population, and there is a lack of information on what normal growth should be in these children. Non-nutritional factors may influence growth, but nutritional factors such as insufficient caloric intake, excessive nutrient losses and abnormal energy metabolism also contribute to growth failure. Malnutrition is associated with significant morbidity, while nutritional rehabilitation improves overall health. Nutritional support should be an integral part of the management of neurologically impaired children, and should focus not only on improving nutritional status but also on improving quality of life for patients and their families. When considering nutritional intervention, oromotor dysfunction, gastroesophageal reflux and pulmonary aspiration must be addressed and a multidisciplinary team should be involved. Children at risk for nutrition-related problems should be identified early. An assessment of nutritional status should be performed at least yearly, and more frequently in infants and young children, or in children at risk for malnutrition. Oral intake should be optimized if safe, but enteral tube feedings should be initiated in children with oromotor dysfunction, leading to clinically significant aspiration, or in children unable to maintain an adequate nutritional status with oral intake. Nasogastric tube feeding should be used for short-term intervention, but if long-term nutritional intervention is required, a gastrostomy should be considered. Antireflux procedures should be reserved for children with significant gastroesophageal reflux. The patient's response to nutritional intervention should be carefully monitored to avoid excessive weight gain after initiation of enteral nutrition, and paediatric formulas should be used to avoid micronutrient deficiencies.