Gastroesophageal Reflux and the Neurologically Impaired Patient

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.