Feeding dilemma: gastro-oesophageal reflux disease and gastrostomy care

Abstract

Feeding children with gastro-oesophageal reflux disease (GORD} is a complex process. The suggested thickened feeding although it slightly improves the number of episodes of regurgitation and weig gain, has no beneficial effects reducing number of acid refluxes and reflux index. In addition, the evidence for using variety of hydrolyzed formulae and added pre and probiotics has not improv the clinical care of children with GORD.Since 1980, the year that the first report of modern percutaneous endoscopic gastrostomy was started, the procedure has revolutionized feeding of children with complex feeding disorders. It has paved the way to address nutritional rehabilitation and prevent micro-aspiration and progressive loss of lung function especially in neurologically handicapped children. Furthermore, the procedure has also improved the quality of life of the caregivers. However, the care of the gastrostomy tube and feeding can be quite complicated. Most neurologically handicapped children have derailed gastrointestinal motility predisposing them to develop delayed gastric emptying which induces gastro-oesophageal reflux. Although iso-osmolar feeds can minimize this problem hyperosmolar feeds are often needed to address the nutritional issues of these children. Whether or not feeds may be delivered by bolus or need initiating by continuous feeds is largely determined by the previous feeding history. Continuous intra-gastric feeds are not physiological and may lead to slower gastric emptying and higher baseline pH values than bolus feeds. The latter promotes bacterial growth, which, particularly in children with significant dysmotility, may further exacerbate this clinical problem. Although excessive bolus feeds may lead to abdominal discomfort and distension blous feeds per se contribute to distal colonic motor suppression, and hence allow better water absorption in the ascending colon. If a feed is administered too rapidly via a PEG, this may, however lead to "dumping syndrome”.