Monday, June 5, 2017

Medical Issues Common In Children With Neurodisability

There are a number of medical problems which are more common in children with disability. These

1. Gastro-esophageal reflux disease (GERD) :Gastro-oesophageal reflux (the non-forceful regurgitation of gastric contents into the esophagus) is more common in children with neuro-developmental problems for a number of reasons. 
Intra-abdominal pressure may be increased for structural reasons such as scoliosis, the lower esophageal sphincter may be functionally immature as a reflection of abnormal muscle tone elsewhere in the body, and difficulties in upright positioning may also exacerbate gastroesophageal reflux.
First line management is postural, with supportive upright seating and sleeping positioners, along with adjustment of feed consistency if required. In addition, pharmacological agents like Proton-pump inhibitors (e.g. omeprazole, lansoprazole, esomeprazole) and H2-receptor antagonists (e.g. ranitidine) are used to alter acid production. Dopamine receptor antagonists (e.g. domperidone) stimulate gastric emptying and small intestinal transit. They also help with GERD by enhancing the tone of the esophageal sphincter. In children with severe symptoms of GORD, surgical intervention such as a Nissen’s fundoplication may be considered.

2. Respiratory complications: Neurological disturbance in children with neurodisability impairs the ability of the child to protect their airway, leading to acute or chronic (‘silent’) aspiration and liability to chemical pneumonitis or secondary infection with anaerobic organisms.
The underlying mechanism leading to aspiration may be abnormal tone of the facial and swallowing
muscles or may be part of a condition causing abnormal tone throughout the body (e.g. cerebral palsy or spinal muscular atrophy). Direct damage to the swallow and respiration control centers may occur for a number of reasons, including traumatic brain injury, stroke or brain tumor.
In addition to the above factors increasing risk of aspiration and thus lung infection, abnormal immune function may be a part of the underlying disorder. An example is Down’s Syndrome, where low tone combines with structural differences and impaired immunity, including low levels of blood immunoglobulins and impaired vaccine responses as well as abnormal lymphocyte subsets.

3. Drooling: Children with neuro-developmental conditions may continue to drool beyond the age of 4 years (which is the age up to which drooling may be considered normal). This may be due to a number of reasons, including:
• Abnormalities in swallowing (as discussed above)
• Difficulties moving saliva to the back of the throat
• Poor mouth closure
• Tongue thrusting.
Intervention may be conservative, including rewarding and behavioral methods, pharmacological or

4. Constipation: Although constipation is common in the pediatric population as a whole, its prevalence is much greater amongst children with neurodisability. 
This may be due to a number of factors, including abnormalities of muscle tone, which includes the muscle of the bowel wall, restricted diet low in fiber due to difficulties in chewing and swallowing, and mobility difficulties (normal upright mobility will aid transit of waste through the bowel). Treatment is via diet and lifestyle modification in combination with one or more laxatives.

5. Temperature regulation : Children with complex neurodisability can present with hypothalamic dysfunction and temperature dysregulation. 
In addition, a child with neurodisability may be unable to voluntarily respond to temperature change,
for example by seeking warmth.

6. Sleep difficulties: Many disabled children have difficulties with sleep initiation or maintenance.
Often children with neurodevelopmental disorders have circadian rhythm abnormalities. This is particularly common in children with ADHD. The other group of children in which circadian rhythm disturbances are more common is those with visual impairment, where environmental clues about sleep can be missed.
Sleep should be managed initially with advice about good sleep hygiene and explanation of the sleep–wake cycle, including normality of short periods of wakening during the night.

7. Orthopedic complications: 
Hip subluxation or dislocation occurs in 60% of children with cerebral palsy who are not walking at the age of five years. It can result in pain, increasing deformity, inability to sit, functional restrictions and may lead to spinal deformity. All children with conditions causing disorders of muscle tone are at risk of hip dislocation, those with hypertonia are at a greater risk than those with hypotonia.
Scoliosis is a lateral curvature of the spine. Children with abnormal tone are at increased risk of spinal deformities due to motor impairment due to absence of normal weight bearing and movement.
Spasticity or low tone can lead to abnormal forces on the spine leading to curvature. Children with neurodisability should be assessed regularly for clinical evidence of spinal deformity and referred promptly for prompt assessment by a specialist spinal team where spinal deformity is detected.

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