Digestive Health

Stomach aches, vomiting, constipation and other common childhood digestive symptoms can be signs of serious problems for children with Cerebral Palsy. A gastroenterologist can diagnose, treat, and sometimes prevent further complications.

Common digestive symptoms could be signs of serious health conditions

When a child with Cerebral Palsy gets a tummy ache, mommy’s kisses may not be enough for it to feel better. Unfortunately, digestive symptoms such as diarrhea, vomiting, constipation or bladder infections may be the first sign of a number of gastrointestinal conditions that require medical attention before they become unmanageable.

The reason is that Cerebral Palsy causes structural abnormalities in both the central and peripheral nervous system that regulate involuntary body functions, such as blood flow, heartbeat, digestion and breathing. Those abnormalities make children with Cerebral Palsy prone to digestive problems that could interfere with their ability to digest food and absorb nutrients. In some cases, children are not able to eat at all.

But, because children with Cerebral Palsy often have difficulty communicating, parents may not realize the serious health risks that these otherwise common childhood conditions present to their child with Cerebral Palsy.

Gastroenterologists, or doctors who specialize in digestive issues, can help.

What is gastroenterology?

Gastroenterology is a medical specialty that focuses exclusively on the functioning, and diseases of, the digestive tract. The role of the physician, or gastroenterologist, is to diagnose the reason for the digestive symptoms, then present options to treat, manage or eliminate the problem altogether. Methods may include dietary changes, medications, surgery or the installation of temporary or permanent feeding tubes.

Among the specific conditions that gastroenterologists treat are:

• Celiac disease
• Crohn’s disease
• Diverticulitis
• Gallbladder disease
• Gastroparesis
• Gastroesophageal reflux disorder
• Hepatitis
• Irritable bowel syndrome
• Pancreatitis
• Peptic ulcers

Why should a child with Cerebral Palsy see a gastroenterologist?

Because of the higher risks for gastrointestinal problems due to the nature of the disease, children with Cerebral Palsy should be seen by a specialist as soon as a parent recognizes digestive symptoms that include:

• Bladder infections
• Bowel and bladder motility
• Constipation
• Difficulty sucking or swallowing
• Failure to feed (infants)
• Pain or discomfort
• Unexplained weight gain, or loss
• Urinary incontinence
• Vomiting

Some of the conditions a child with Cerebral Palsy may face include:

Secondary undernourishment – Most children with Cerebral Palsy are at risk for secondary undernourishment due to feeding difficulties and oral motor dysfunction. Oral motor dysfunction is the inability to control muscles in the mouth required for proper food intake levels. Children with Cerebral Palsy can benefit from feeding and nutrition assessments.

A study published July 1, 1999 by Elsevier titled “Gastrointestinal manifestations in children with Cerebral Palsy” found the majority (92%) of those with Cerebral Palsy had one or more significant gastrointestinal symptoms, including difficulty swallowing, regurgitation, abdominal pain, chronic pulmonary aspiration, and chronic constipation.

Elsevier also found 93% of those with trouble swallowing had oral dysfunction and/or pharyngeal phase swallowing difficulties. Swallowing occurs in three phases. Difficulties in swallowing can occur at one or more of the phases:

• Oral phase – food is placed in the mouth, moistened and chewed to proportionally size the food for passage to the pharynx.
• Pharyngeal phase – sensory receptors activate involuntary and rhythmic contractions that push the food from the pharynx to the esophagus. The larynx temporarily inhibits breathing to protect the lungs.
• Esophageal phase – food progresses from the esophagus to the stomach through rhythmic contractions. Esophageal sphincters open and close to provide physical barriers to avoid regurgitation.

Aspiration or respiratory issues – Among the most serious concerns of parents who have a child with Cerebral Palsy are aspiration and respiratory complications. Aspiration occurs when fluids enter the lungs and can cause infection, choking or airway obstructions. Having respiratory and digestive problems makes risks of complications higher for both conditions.

Some of the symptoms of respiratory issues include:

• Breathing problems
• Coughing
• Sleep apnea
• Wheezing

Diarrhea – Elimination of abnormal stools or liquid is commonly the result of viruses, certain medications, food poisoning and stress. Persistent or prolonged incidents can indicate a more serious problem. The episodes themselves can cause dehydration, stomach pain and discomfort that will inhibit a child from eating, all concerns that warrant a visit to the doctor. If there’s blood in the stool, call immediately.

Diarrhea is often an associated condition of IBS, Crohn’s disease, ulcerative colitis, GERD, bacterial infections, allergies or other issues originating in, or associated with, the digestive system.

Dysphagia – Dysphagia is a condition of the throat and esophagus that interferes with a child’s ability to swallow food or liquids. It is commonly seen in children with moderate to several Cerebral Palsy. Dysphagia has two sub-categories:

• Oropharyngeal dysphagia is the result of abnormalities in the muscles and nerves of the oral cavity, pharynx and esophageal sphincter.
• Esophageal dysphagia is the result of the malformations, or a malfunction, of the lower esophageal sphincter that causes motility issues.

Some of the symptoms of dysphagia include:

• Apnea during feeding
• Coughing
• Delayed swallowing reflex
• Fatigue
• Feeling of having an obstruction shortly after swallowing
• Physical reactions while feeding such as frowning
• Tongue thrust

Gastroesophageal reflux disorder – Commonly called GERD or acid reflux disease, this condition is caused by mucosal damage that occurs when acid is regurgitated from the stomach back into the esophagus. A change in the structural barrier between the stomach and esophagus and a relaxation of the lower esophageal sphincter allows acid to re-enter the esophagus.

GERD can be difficult to diagnose in children who have difficulty communicating their digestive symptoms. If left untreated, GERD can cause esophagitis, esophageal narrowing, ulcers and esophageal cancer.

Some of the symptoms of GERD include:

• Aspiration
• Belching
• Coughing
• Drooling
• Excessive crying
• Halitosis
• Heartburn
• Indigestion
• Refusal to bottle or breast feed
• Regurgitation
• Sore throat
• Spitting up
• Unexplained weight loss
• Vomiting
• Wheezing

Irritable bowel syndrome – Known as IBS, this condition is one that changes how the GI tract works. The GI tract is the series of organs that extend from a person’s mouth to the anus and is responsible for digesting food. It’s not considered a disease, but a group of symptoms that can cause pain and discomfort on a consistent basis.

Some of the symptoms of IBS include:

• Abdominal pain
• Bloating
• Constipation
• Diarrhea
• Flatulence

Malnutrition – Children who are unable to swallow or process nutrients properly may become malnourished. This can be particularly troublesome for infants, who may refuse food because of makes them feel worse. If a child consistently rejects food, or appears to be losing weight, make a doctor’s appointment.

Nutritional assessment is beneficial for identifying digestive dysfunction

A study published March 3, 2000, in Developmental Medicine & Child Neurology by Department of Paediatrics at the University of Oxford in the United Kingdom found feeding problems are common and severe, particularly among those with neurological impairment – yet only 64% of the children had undergone feeding and nutrition assessment. Of the parents of children with oral motor dysfunction who responded to the survey, 93% had children diagnosed with Cerebral Palsy. Of the children with gastrointestinal problems:

• 59% were constipated
• 22% had significant problems with vomiting
• 31% had at least one chest infection within a six month period
• 89% needed assistance with feeding
• 56% choked with food
• 28% had prolonged feeding times

Other associative conditions may include recurrent vomiting, chronic pulmonary aspiration, diarrhea, choking, pneumonia, and flatulence.

Feeding difficulties may lead to less than ideal food intake, causing undernourishment, failure to thrive, malnutrition, growth delay, and gastroenterological conditions. Intestinal dysmotility, delayed gastric emptying, and reflux may lead to an increased risk of food aspiration and pneumonia.

Oral motor dysfunction also causes speech, drooling, sucking, chewing, and swallowing difficulties and can lead to a significant increase in the length of time required for feeding. As a result, many children with Cerebral Palsy are on liquid and semi- solid foods. Some are tube fed, while others may be prescribed a combination of food and tube feedings.

What happens during an appointment with a gastroenterologist?

After the initial evaluation of the child’s overall health, including previous and existing medical conditions, the gastroenterologist will hone in on specific symptoms and their possible relationship to other medical issues. Further testing is often required to pinpoint the cause of the problem.

CT scans or magnetic resonance imaging, or MRI, may be ordered to assess gastrointestinal health and aspiration. Intraesophageal pH can be monitored or an upper GI endoscopy may be required to determine reflux and vomiting disorders. Eating ability and nutritional needs can be evaluated. Body mass index and fat-free mass can be compared to the child’s age, height, weight and form of Cerebral Palsy to gauge growth and developmental level. The length of time for feeding and the severity of impairment will help determine feeding strategy.

Common tests used by gastroenterologists and other specialists to diagnose digestive conditions include:

• Abdominal angiogram
• Abdominal ultrasound
• Barium enema
• Barium swallow
• Biopsy
• Blood tests
• Cholecystectomy
• Cholecystography
• Colonoscopy
• CT scans of the abdomen, liver, and biliary tract
• Endoscopy
• Laparoscopy
• Lower GI x-rays
• Videofluoroscopy tests (if a child aspirates)

What training and qualifications to look for in a gastroenterologist

Gastroenterologists must first complete eight years of higher education, which includes general education with an emphasis on medicine and four years of specialty medical training. To practice gastroenterology, they must also complete a three-year residency program in internal medicine at a fully-accredited hospital followed by a fellowship that focuses exclusively on gastroenterology.

During this fellowship, physicians will undergo extensive training in diagnosis, management, and treatment of digestive diseases.

Upon successful completion of all the required courses and training, physicians must get approval from the American Board on Internal Medicine to take the gastroenterology exam. The ABIM administers the exam, and grants certification and license based on an applicant’s favorable score on the exam.

Gastroenterology services typically take place in an outpatient setting at a physician’s office. However, there are other places and circumstances where a child may undergo treatment, including:

• Acute care centers
• Clinics
• Hospitals
• Long-term care facilities and nursing homes
• Rehabilitation centers

What non-surgical treatments are available?

Children who have trouble digesting food may be treated with non-surgical interventions, including dietary changes and/or medications. Some children may be referred to therapists who can help them learn new strategies to swallow foods and liquids, while others may require surgical interventions.

The multi-disciplinary team of experts is likely to recommend timely rehabilitation and nutritional interventions to improve nutritional status and quality of life. Nutritional interventions may include increasing the quality of food, increasing fluid intake, and forming individualized meal plans with specified quantities and consistencies of food. High energy nutrition supplements may be required. Medications (prokinetic drugs, antacids and gastric enzyme inhibitors) may be prescribed.

If oral-motor dysfunction is causing digestive problems, new positioning techniques, external appliances, and food consistency alterations are often successful remedies. Some children with Cerebral Palsy can swallow softer foods, or liquids that have some consistency.

Eliminating foods and beverages that trigger digestive issues is typically an easy solution, especially in treating GERD. Among the triggers of discomfort are chocolate, acidic juices, high-fat and spicy foods, and carbonated soft drinks.

Medications such as proton-pump inhibitors paired with H2 receptor blockers have shown some promise in easing symptoms of GERD.

Feeding technique instruction can improve feeding mechanics. Therapy may improve head control, feeding skills, and speech.

Treatments and lifestyle changes should be discussed with the child’s primary care physician or digestive health specialist before they are implemented.

What are feeding tubes, and what should parents know about them?

A feeding tube delivers liquid nutrients to a person who, either permanently or temporarily, cannot consume or digest food. It may be the most effective treatment for children with oral-motor dysfunction who don’t respond to the other non-surgical treatments listed above.

There are two types of feeding tubes:

Nasogastric tube, or NG tube, is placed through the nose to introduce food to the stomach. This is usually considered a short-term option as the tube may interfere with swallowing and vomiting reflexes. One advantages of an NG tube is that it is relatively easy to put into place, and it can be changed or removed without surgery.

Other tubes that are similar to the NG tube include the nasojejunal, or NJ-tube, which is threaded into the jejunum, located in the small intestine, and the nasoduodenal, or ND-tube, which is inserted into the duodenum. Both deliver vital nutrients to people unable to tolerate feeding directly into a dysfunctioning stomach.

Gastreonomy tube, or G-tube, is intended as a long-term remedy, but requires surgery. It is inserted through the abdominal wall into the stomach allowing for uninterrupted oral feeding while supplementing nutrients. The G-tube can also be used for gastric draining, or siphoning bile and acid that collects in the stomach because of a blockage in the small intestine.

Other tubes that are similar to the G-tube includes the gastrojejunostomy tube, or GJ-tube, which is intended for people with extreme gastric motility issues, and is capable of simultaneously feeding a person while venting and draining the stomach, and the jejunostomy tube, or J-tube, which is inserted into the jejunum, and can be helpful for persons that have gastric motility issues.

Do feeding tubes carry any associated risks?

Feeding tubes can improve overall health for people who have no other safe methods to consume food. However, the surgery required does have risks. Like any surgery, feeding tube installation can cause infection at the surgery site. However, additional risks during installation of the tube can also occur.

A nasogastric tube that sends liquids to the stomach requires the tip of a tube to rest in the stomach. If installed incorrectly, the tip can interfere with respiratory functioning, which, in turn, can force liquid food into the lungs, putting the child at risk for pneumonia.

Incorrect insertion of a gastrostomy tube can cause leakage, which can result in peritonitis – inflammation of the tissue that lines the inner wall of the abdomen. If not treated promptly, bacteria can spread to the blood and other organs, resulting in multiple organ failure and death. Studies show that G-tube insertion and removal is generally safe and that complications are rare.

How can surgery help a child with digestive issues?

The most common surgery that children with moderate to severe Cerebral Palsy undergo is installation of a feeding tube, but not until all other non-surgical options have failed.

However, there are other surgeries that children may undergo to help resolve digestive issues, and ease pain and discomfort. Among them is the Nissen fundoplication surgery to ease GERD symptoms. During this procedure, a valve is inserted at the top of the stomach to reduce recurrent vomiting, chest infections and acid reflux disease.

Hiatal hernias can be repaired using the same methods that surgeons use on adults with the same issues. In severe cases, comprehensive gastroenterological surgery can re-route the systems that digest food in the human body.

A surgical procedure that can help address a child’s drooling is called a submandibular duct relocation. And, children with urinary incontinence or a lack of bladder capacity can undergo bladder augmentation cystoplasty.

Before agreeing to any surgery, try all the non-surgical options available. If surgery offers the most hope for a better quality of life, discuss risks and possible outcomes with the surgeon. If questions aren’t answered, get a second opinion.

Some common gastrointestinal, nutritional and dietary conditions may include:

• Abdominal pain
• Aspiration
• Bladder control
• Bowel (intestinal) obstruction
• Bowel incontinence
• Chewing difficulties
• Choking
• Chronic pulmonary aspiration
• Constipation
• Delayed gastric emptying
• Delayed growth and development
• Dental caries/tooth decay
• Diarrhea
• Drooling
• Enuresis (bed wetting)
• Esophageal bleeding
• Esophagitis
• Failure to thrive
• Feeding difficulties
• Flatulence
• Gastroesophageal disease
• Gastroesophageal reflux (GERD)
• Gastrointestinal motility
• Gastrointestinal tract bleeding
• Genitourinary problems
• Growth impairment (maturation)
• Halitosis
• Immobilization
• Inadequate oral intake
• Incontinence
• Intestinal dysmotility
• Irritable bowel syndrome
• Malnutrition
• Obesity and weight management
• Oral motor dysfunction
• Pneumonia
• Primary intestinal pseudo obstruction
• Prolonged colonic transit
• Pseudobulbar palsy
• Sucking difficulties
• Swallowing difficulties
• Undernourishment
• Urinary incontinence
• Urinary tract infections
• Vitamin deficiency
• Vomiting