Is surgery or medical treatment more effective in treating acid reflux in brain damaged children having a feeding tube inserted

Vernon-Roberts A, Sullivan PB

Published Online:

October 7, 2009

Children with cerebral palsy often have oral motor impairment and need help with eating and drinking. Frequently this entails surgery to place a feeding tube (gastrostomy) directly into their stomach. They may also be found to have gastro-oesophageal reflux (where stomach acid flows back up into the oesophagus) which can be made worse by gastrostomy surgery. Reflux can be treated either with additional surgery at the same time as the gastrostomy (a fundoplication) or with anti-reflux medications. This review was carried out to determine which was the safest and most effective form of treatment. We found no randomised controlled trials that provided scientific evidence on which to base a conclusion, which highlighted the need for a trial comparing the two interventions.

Abstract (click to read)

Background:

Children with neurological impairments (NI) frequently experience feeding difficulties which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with NI who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical anti-reflux treatment in the form of a fundoplication, or other Anti-Reflux Procedures. Fundoplication is associated with a high recurrence rate, surgical failure and significant morbidity and mortality.

Since Proton Pump Inhibitors (PPIs) were introduced in the 1990s they have come to play a larger part in the medical management of GOR in children with NI. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations.

There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice.

Objectives:

To compare the effectiveness of anti-reflux surgery and anti-reflux medications for children with NI and GOR who are undergoing placement of a gastrostomy feeding tube.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) up to Issue 2, 2009, MEDLINE (1966 to June 2009), EMBASE (1980 to week 23, 2009), CINAHL (1982 -to Dec 2008), LILACS (1982 to June 2009), ISI Web of Science (1970 to June 2009) and the Child Health Library (searched June 2009). We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. Specialists in the medical and industry setting were contacted for knowledge of completed or ongoing trials.

Selection criteria:

We sought to include only randomised controlled trials that recruited children up to the age of 18 years with NI and GOR who were undergoing gastrostomy tube insertion.

Data collection and analysis:

Review authors worked independently to select trials; none were identified.

Main results:

No trials were identified that satisfied the criteria for this review.

Authors' conclusions:

There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus anti-reflux medications for gastro-oesophageal-reflux in the child with neurological impairment who is undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.

This record should be cited as:

Vernon-Roberts A, Sullivan PB. Fundoplication versus post-operative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD006151. DOI: 10.1002/14651858.CD006151.pub2

Assessed as up to date:

August 11, 2009

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Primary Review Group:

Developmental, Psychosocial and Learning Problems Group

Health topics:

Developmental, psychosocial, and learning problems > Developmental problems > Neurodevelopmental disorders

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Is surgery or medical treatment more effective in treating acid reflux in brain damaged children having a feeding tube inserted

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