0
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 50.19.47.197. Please contact the publisher to request reinstatement.
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Rates and Risks of Gastrostomy Tubes in Infants With Cleft Palate FREE

Sharon R. Cu, BS; James D. Sidman, MD
[+] Author Affiliations

Author Affiliations: Departments of Otolaryngology, Children's Hospitals and Clinics of Minnesota and University of Minnesota (Ms Cu and Dr Sidman), and Pediatric ENT Associates (Dr Sidman), Minneapolis.


Arch Otolaryngol Head Neck Surg. 2011;137(3):275-281. doi:10.1001/archoto.2011.18.
Text Size: A A A
Published online

Objectives  To review data on a cohort of infants with cleft palate to (1) determine rates of gastrostomy (G)-tube placement, (2) identify contributing comorbidities, and (3) use relative risk analyses to improve management of cleft palate in infants with feeding difficulty.

Design  Retrospective medical record review.

Setting  Tertiary care children's hospital.

Patients  Infants with cleft palate born between January 1, 2000, and December 31, 2008, without G-tubes prior to referral were included. Comorbidities were analyzed, including syndromes and chromosomopathies (syn/chrom) and cardiac, respiratory, neurologic, and gastrointestinal diagnoses. These comorbidities were analyzed independently.

Main Outcome Measure  Gastrostomy-tube placement.

Results  Of 214 infants with cleft palate, 34 required G-tubes. Of these, 19 had syn/chrom. Independent of these diagnoses, 17 infants had 1 system comorbidity and 12 had multisystem comorbidities. Of the 180 patients without G-tubes, 20 had syn/chrom. Independent of these diagnoses, 10 infants had 1 system comorbidity and 2 had multisystem comorbidities. Rates of G-tube placement ranged from 3% in infants without any comorbidity to 94% in infants with respiratory comorbidity. Relative risks of G-tube placement with syn/chrom, 1 system comorbidity, and multisystem comorbidities were 5.68 (95% confidence interval, 3.18-10.16), 21.79 (8.76-54.17), and 29.66 (12.18-72.21), respectively.

Conclusions  Diagnosis of syn/chrom or major comorbidity significantly increases risk of G-tube placement. Regardless of syn/chrom association, problems affecting the heart, respiratory system, central nervous system, and lower esophageal sphincter are the most significant risk factors, implying that particular comorbidities are more influential than a simple diagnosis of syn/chrom. These data should help identify children at greatest risk for G-tubes and those expected to overcome feeding difficulties, leading to more persistent use of nonsurgical therapy before resorting to G-tubes.

Cleft lip and palate are congenital defects that can occur alone or be associated with a wide variety of syndromes and other abnormalities. As infants await surgical correction of cleft palate, proper nutrition and growth must be maintained. Children with cleft palate have trouble generating an adequate suck because of the palatal defect. Poor suction results from insufficient seal formation between the nasopharynx and oropharynx, preventing enough negative pressure for normal food intake and bolus formation in the oral stage of swallowing.1 At the very least, anterior or posterior closure of the oral cavity is necessary.2

Despite multiple studies attempting to quantify measures of feeding function with standardized scales, such as the Neonatal Oral Motor Assessment Scale and Great Ormond Street Measurement of Infant Feeding, as well as videofluoroscopy and electromyograms,3 there remains to be developed a good and practical protocol to determine feeding strategies. Both objectively and subjectively, the degree of difficulty in feeding infants with cleft abnormalities depends on the degree of the deformity. It is well documented that syndromic infants require more substantial feeding interventions, leading to higher rates of enteric feeding (Table 1). The rates given in Table 1 were collected incidentally by the authors of each study while examining other aspects of feeding in infants with cleft abnormalities. The purpose of our study was to (1) determine rates of gastrostomy (G)-tube placement, (2) identify contributing comorbidities, and (3) use relative risk analyses to improve management of cleft palate in infants with feeding difficulty.

Table Graphic Jump LocationTable 1. Rates of Enteric Feeding in Nonsyndromic and Syndromic Infants

The institutional review board approved the medical record analysis used for this study. Medical records of patients monitored by a multidisciplinary cleft team at the Children's Hospital and Clinics of Minnesota–Minneapolis site were retrospectively reviewed. All patients with cleft palate born at this tertiary care children's hospital between January 1, 2000, and December 31, 2008, were identified and the following inclusion criteria were used: first examination in infancy (<1 year of age, as determined by available consult notes, summary cleft clinic notes, and operative reports), no prior G-tube feeds, unrepaired cleft palate, and eventual repair by a surgeon on our cleft team. The minimum defect required for inclusion was cleft palate. There was no distinction made between infants with isolated cleft palate and those with both cleft lip and palate. The electronic medical records of these patients were analyzed for documentation of G-tube placement and comorbidities, including cardiac, neurologic, respiratory, and gastrointestinal defects both independent of and associated with syndromes and/or chromosomopathies (syn/chrom). Chromosomopathies included unnamed deletions, translocations, and partial trisomies. Major surgical procedures, such as repair of congenital heart defects, tracheostomy, distraction osteogenesis of the mandible, Nissen fundoplication, Ladd procedure, and ventriculoperitoneal shunt placement, were tracked to help qualify the severity of each disease. For example, only atrial septal defects and ventricular septal defects requiring operations were analyzed as cardiac comorbidities and only gastroesophageal reflux disease failing swallow study or requiring Nissen fundoplication were analyzed as gastrointestinal (reflux) or respiratory (aspiration) comorbidities.

A total of 214 patients met the inclusion criteria. The main reasons for exclusion were cleft palate repaired by surgeons from other groups (n = 35), absence of operative note in the electronic medical record (n = 35), prior G-tube placement (n = 7), care primarily received at other institutions (n = 5), and adoption of patient with unknown early medical history (n = 2).

The patients were separated into 2 groups based on the placement of G-tubes. Patients were then separated further into overlapping subgroups: those with syn/chrom, those with only 1 system comorbidity, and those with multisystem comorbidities. The incidence of the comorbidities was determined in each group (G-tube vs no G-tube), and comparisons were made using relative risk (RR) ratios with 95% confidence intervals.

Statistical calculations were performed according to the Principles of Biostatistics.13 Infants with syn/chrom, 1 system comorbidity, and multisystem comorbidities were considered to be at risk. Those at risk who required G-tubes were designated a. Those at risk who did not require G-tubes were designated b. Infants without syn/chrom or without any major system comorbidities were considered to have no risk factors. Those not at risk who required G-tubes were designated c. Those not at risk who did not require G-tubes were designated d. The RR calculations compared infants with syn/chrom vs those with no syn/chrom, 1 system comorbidity vs no comorbidities, and multisystem comorbidities vs no comorbidity according to the following equation: RR = [a /(a + b)]/[c /(c + d)]. Confidence intervals were determined by standard error, calculated as SE = square root ({ b/[a × (a + b)]}+{ d/[c × (c + d)]}), and the following equation: RR × e exp[±1.96 × (SE × RR)].

Demographic information of the 214 patients diagnosed as having cleft palate who met the inclusion criteria is displayed in Table 2. Incidence of syn/chrom is given in Table 3. Of the 214 patients, 34 infants (15.9%) required G-tubes, while the remaining 180 (84.1%) did not. In the population requiring G-tubes, 19 infants (55.9%) had syn/chrom, 17 (50.0%) had 1 system comorbidity, and 12 (35.3%) had multisystem comorbidities. Only 5 patients (14.7%) required G-tubes because of courses that were poorly described; however, documentation did show that 1 of these 5 patients had experienced a failed trial (due to infection) of G-tube placement prior to our care, and mandibular distraction osteogenesis may have failed in another infant based on the distraction and G-tube placement dates.

Table Graphic Jump LocationTable 2. Characteristics of the Study Population
Table Graphic Jump LocationTable 3. Incidence of Syndromes and Chromosomopathiesa

In the population not requiring G-tubes, 20 infants had syn/chrom (11.1%), another 10 (5.6%) had 1 system comorbidity, and 2 (1.1%) had multisystem comorbidities. The RRs of G-tube placement for the syn/chrom vs no syn/chrom population was 5.68 (95% confidence interval, 3.18-10.16). The RR for G-tube placement for the populations with 1 system comorbidity and multisystem comorbidities vs those with no comorbidities were 21.79 (95% confidence interval, 8.76-54.17) and 29.66 (12.18-72.21), respectively.

Of all comorbidities, the highest rates for G-tube placement occurred in patients with respiratory system defects, both independently as the sole diagnosis (85.7%) and in conjunction with other diagnoses (93.8%). The lowest incidence of G-tube placement was in patients without syn/chrom or comorbidity (2.9%). For further summary of results, see Tables 4,5,6,7, and 8.

Table Graphic Jump LocationTable 5. Comorbidities of Patients With and Without Gastrostomy Tubes
Table Graphic Jump LocationTable 6. Enteric Feeding in Patients With and Without Syndromes and/or Chromosomopathies
Table Graphic Jump LocationTable 7. Enteric Feeding in Patients With 1, 2 or More, and No Major System Comorbidities
Table Graphic Jump LocationTable 8. Comorbidities and Indications for G-Tube Placement in Infants Requiring G-Tubes

This study is significant because infant feeding problems are detrimental to both patients and parents. In the child, they can lead to serious complications, such as malnutrition and failure to thrive in addition to discomfort during feeding, with nasopharyngeal regurgitation, bloating from excessive air intake, choking, coughing, gagging, and fatigue from long feedings.1,10 Feeding problems can also increase time to surgical repair of the cleft palate.4 For parents, feeding is one of the most pressing concerns after learning of the cleft diagnosis,14 and some mothers experience disappointment, guilt, or confusion when faced with difficulty breastfeeding.15

Several strategies are used to diminish feeding complications before G-tube placement is necessary. However, the majority of strategies are not supported by compelling evidence. Reid16 identified 5 main categories of feeding strategies: equipment, technique, breastfeeding, prostheses, and nutrition/lactation advice. Combinations of these strategies are often used. Feeding equipment may range from compressible bottles that overcome inadequate suck, such as the Mead Johnson or Haberman feeders; specialized orthodontic nipples; and nasogastric tubes, orogastric tubes, and G-tubes.1,7 Positional considerations, such as semiupright and upright feeding, have been proposed to reduce nasal regurgitation and poor airway protection.1,4 Breastfeeding can be accomplished with less severe palatal defects. However, while many cleft palate studies expound the benefits of breastfeeding, most point out that breastfeeding alone in the presence of cleft palate results in inadequate oral intake. Breast milk may be provided via special feeders or, like formula, may be thickened to enhance caloric density for adequate nutrition. Prostheses can be placed inside the infant's mouth to help better seal the oropharynx during feeding. Success and adherence using these devices are questionable,17 but they have been shown to work on a case basis, and efforts have been made to make them more comfortable for the infant.18 Finally, parent education and support have been useful in countering failure to thrive.4 Referrals to nutrition and feeding specialists are certainly appropriate, particularly in refractory cases.

In infants with additional anatomic defects, protective measures to avoid G-tube placement may be invasive. For example, in infants with the micrognathia and glossoptosis of Pierre Robin syndrome (PRS), which make the mechanics of swallowing and the ability to protect the airway even more challenging, corrective jaw surgery may be indicated. One retrospective study6 of 115 patients with PRS showed that 44% underwent operative airway management and 39% underwent tracheotomy, but 42% of patients nevertheless required G-tube placement. In a study9 of 67 patients with PRS, children were divided into syndromic and nonsyndromic subgroups with early (within 3 months of birth) or late airway intervention. The conditions of all nonsyndromic patients with PRS and early distraction osteogenesis or tracheotomy were able to be managed without a G-tube. Overall, approximately 10% of the nonsyndromic patients with PRS required a G-tube, while 75% of the syndromic patients eventually needed G-tubes.

Despite attempts to avoid G-tube placement, some patients still require them, most often because of malnutrition, failure to thrive, gastroesophageal reflux, or aspiration (Table 8). Complications of gastrostomy include gastroesophageal reflux, infection, formation of granulation tissue, tube dislodgement, intra-abdominal leaks, gastrocolic fistulae, and oral aversion.19 Thus, it is beneficial to determine which patients are at greatest risk for requiring this intervention. The wide range of G-tube feeding rates in previous studies (Table 1) illustrates the influence of comorbidities. In our study, rates were as low as 3% in infants with cleft palate with no comorbidity and as high as 94% in infants with respiratory comorbidity.

The complications caused by the neurologic, gastrointestinal, cardiac, and respiratory comorbidities and their influence on G-tube placement are not surprising. For example, one recent study20 showed that patients with motor neuron diseases who received G-tubes had better nutrition and survival than counterparts without such invasive interventions, citing well-known complications, such as diminished oral intake. This finding is consistent with those of our study, in which insufficient tone or mental capacity to orchestrate deglutition led to similar decreased oral intake. Feeding tubes have been known to aid nutrition in neurologically disabled children with esophageal dysmotility.21

Gastrointestinal complications in this study consisted primarily of gastroesophageal reflux, hiatal (both sliding and paraesophageal) hernias, and aspiration (which was classified under “respiratory” complications for its effect on oxygen saturation). These problems clearly contribute to other aspects of the alimentary tract problems, such as oral feeding. Some studies even suggest resorting to continued G-tube feeds if reflux symptoms are intractable to fundoplication.22

Feeding difficulties in patients with cardiac anomalies, including the relatively common endocardial cushion defects, have been described for decades. Poor appetite, fatigue with feeding, and failure to thrive are symptoms that warrant further cardiac workup.23 Infants with poor cardiac output often burn too many calories in the feeding process, and their nutritional status cannot keep up with the stress and discomfort of feeds. In these cases, intervention is indicated.24,25

Respiratory comorbidities are also understandably associated with feeding difficulties, as protection of the airway is imperative in the normal swallowing mechanism. Silent aspiration leading to chronic feeding difficulty is one independent cause of complications.26 Respiratory comor bidities may also be related to neurodevelopmental abnormalities,27 gastroesophageal reflux,28 or airway protection and aspiration complications, such as in PRS.29 In this study, respiratory comorbidity was the most common factor in increasing risk for G-tube, both alone and in combination with other system comorbidities.

Srinivasan et al30 conducted a study examining the indications for G-tube placement in all children and concluded that the most common causes were neurologic disorders, followed closely by congenital heart defects. Distant third and fourth indications were respiratory related, and the diagnosis of cleft palate completed the top 5 indications. However, on closer inspection, when considering only G-tubes placed at average patient age younger than 1 year, the top 3 indications listed were cleft lip/palate, congenital heart disease, and chronic lung disease at ages 0.36, 0.39, and 0.73 year, respectively. These leading causes for G-tube placement in infancy agree with our study's findings, which show that, within cleft palate indications, comorbidities affecting other systems—specifically cardiac and respiratory—and other physiologic mechanisms (ie, not just the sucking and swallowing defects) are important determinants.

One potential limitation of our study is that the feeding interventions prior to G-tube placement were not standardized. In the past decade, the evaluation process of infants with cleft palate has become fairly consistent, with cleft nurses often meeting with parents within 1 week of their child's birth and introducing such interventions as the Haberman feeder and upright feeding. In our study, use of the Medela Special Needs Feeder (formerly called the Haberman feeder) (Medela, Inc, McHenry, Illinois) was unsuccessful in 24 of the 34 infants requiring G-tubes, and modified bottles and surgical intervention for infants with PRS worked very well for those not requiring G-tubes (116 used the Haberman feeder as the bottle of choice, 7 used the Mead Johnson Cleft Palate Nurser (Mead Johnson, Evansville, Indiana), 6 used the Pigeon Cleft Palate Nurser (Galtak Houseware Ltd, Markham, Ontario, Canada), 5 used the Playtex VentAire Bottle (Playtex Products Inc, Westport, Connecticut), and 11 required distraction osteogenesis of the mandible for definitive feeding management) (data not shown). However, no conclusions can be made about the overall algorithm for decision making regarding feeds, and we hope that future studies can provide such helpful information.

This study demonstrates the importance of neurologic, gastrointestinal, cardiac, and respiratory comorbidities in indicating the need for G-tube placement in infants with cleft palate. In our study, rates were as low as 3% in infants without any comorbidity and as high as 94% in infants with respiratory comorbidity. The diagnosis of a cleft syn/chrom significantly increased the relative risk of G-tube placement, and the particular syndrome may help in determination of whether a G-tube is indicated, as the type and incidence of many syndromes differed between the 2 populations. Nevertheless, the effect of syn/chrom pales in comparison with the relative risks imposed by specific system comorbidities, both independently and in conjunction with other system involvement. Thus, it seems that which system is involved and the degree to which the system is impaired are more influential than a simple diagnosis of syn/chrom. Patients with neurologic, gastrointestinal, cardiac, and respiratory comorbidities are at increased risk for G-tube placement, with respiratory comorbidity appearing to confer the greatest risk. It is our hope that with this information, infants with cleft palate who are at highest risk for G-tube placement can be identified effectively and aggressive measures to orally feed these infants as well as those at lower risk can be undertaken successfully.

Correspondence: James D. Sidman, MD, Pediatric ENT Associates, Children's Specialty Center, 2530 Chicago Ave S, Ste 450, Minneapolis, MN 55404 (sidma001@umn.edu;cuxxx003@umn.edu).

Submitted for Publication: July 26, 2010; final revision received October 12, 2010; accepted November 25, 2010.

Author Contributions: Ms Cu and Dr Sidman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Cu and Sidman. Acquisition of data: Cu. Analysis and interpretation of data: Cu and Sidman. Drafting of the manuscript: Cu and Sidman. Critical revision of the manuscript for important intellectual content: Cu and Sidman. Statistical analysis: Cu. Administrative, technical, and material support: Cu and Sidman. Study supervision: Sidman.

Financial Disclosure: None reported.

Cooper-Brown  LCopeland  SDailey  S  et al.  Feeding and swallowing dysfunction in genetic syndromes. Dev Disabil Res Rev 2008;14 (2) 147- 157
PubMed Link to Article
Reid  JReilly  SKilpatrick  N Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 2007;44 (3) 312- 320
PubMed Link to Article
Baudon  JJRenault  FGoutet  JM  et al.  Assessment of dysphagia in infants with facial malformations. Eur J Pediatr 2009;168 (2) 187- 193
PubMed Link to Article
Amstalden-Mendes  LGMagna  LAGil-da-Silva-Lopes  VL Neonatal care of infants with cleft lip and/or palate: feeding orientation and evolution of weight gain in a nonspecialized Brazilian hospital. Cleft Palate Craniofac J 2007;44 (3) 329- 334
PubMed Link to Article
Baujat  GFaure  CZaouche  AViarme  FCouly  GAbadie  V Oroesophageal motor disorders in Pierre Robin syndrome. J Pediatr Gastroenterol Nutr 2001;32 (3) 297- 302
PubMed Link to Article
Evans  AKRahbar  RRogers  GFMulliken  JBVolk  MS Robin sequence: a retrospective review of 115 patients. Int J Pediatr Otorhinolaryngol 2006;70 (6) 973- 980
PubMed Link to Article
Garcez  LWGiugliani  ER Population-based study on the practice of breastfeeding in children born with cleft lip and palate. Cleft Palate Craniofac J 2005;42 (6) 687- 693
PubMed Link to Article
Li  HYLo  LJChen  KSWong  KSChang  KP Robin sequence: review of treatment modalities for airway obstruction in 110 cases. Int J Pediatr Otorhinolaryngol 2002;65 (1) 45- 51
PubMed Link to Article
Lidsky  MELander  TASidman  JD Resolving feeding difficulties with early airway intervention in Pierre Robin sequence. Laryngoscope 2008;118 (1) 120- 123
PubMed Link to Article
Reid  JKilpatrick  NReilly  S A prospective, longitudinal study of feeding skills in a cohort of babies with cleft conditions. Cleft Palate Craniofac J 2006;43 (6) 702- 709
PubMed Link to Article
Smedegaard  LMarxen  DMoes  JGlassou  ENScientsan  C Hospitalization, breast-milk feeding, and growth in infants with cleft palate and cleft lip and palate born in Denmark. Cleft Palate Craniofac J 2008;45 (6) 628- 632
PubMed Link to Article
Smith  MCSenders  CW Prognosis of airway obstruction and feeding difficulty in the Robin sequence. Int J Pediatr Otorhinolaryngol 2006;70 (2) 319- 324
Link to Article
Pagano  MGauvreau  K Principles of Biostatistics.  Belmont, CA Duxbury Press1993;
Chuacharoen  RRitthagol  WHunsrisakhun  JNilmanat  K Felt needs of parents who have a 0- to 3-month-old child with a cleft lip and palate. Cleft Palate Craniofac J 2009;46 (3) 252- 257
PubMed Link to Article
Johansson  BRingsberg  KC Parents' experiences of having a child with cleft lip and palate. J Adv Nurs 2004;47 (2) 165- 173
PubMed Link to Article
Reid  J A review of feeding interventions for infants with cleft palate. Cleft Palate Craniofac J 2004;41 (3) 268- 278
PubMed Link to Article
Masarei  AGSell  DHabel  AMars  MSommerlad  BCWade  A The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants. Cleft Palate Craniofac J 2007;44 (3) 321- 328
PubMed Link to Article
Karayazgan  BGunay  YGurbuzer  BErkan  MAtay  A A preoperative appliance for a newborn with cleft palate. Cleft Palate Craniofac J 2009;46 (1) 53- 57
PubMed Link to Article
Peters  RTBalduyck  BNour  S Gastrostomy complications in infants and children: a comparative study. Pediatr Surg Int 2010;26 (7) 707- 709
PubMed Link to Article
Rio  AEllis  CShaw  C  et al.  Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease. J Hum Nutr Diet 2010;23 (4) 408- 415
PubMed Link to Article
Sullivan  PB Gastrointestinal disorders in children with neurodevelopmental disabilities. Dev Disabil Res Rev 2008;14 (2) 128- 136
PubMed Link to Article
Godbole  PMargabanthu  GCrabbe  DC  et al.  Limitations and uses of gastrojejunal feeding tubes. Arch Dis Child 2002;86 (2) 134- 137
PubMed Link to Article
Saenz  RBBeebe  DKTriplett  LC Caring for infants with congenital heart disease and their families. Am Fam Physician 1999;59 (7) 1857- 1868
PubMed
Ciotti  GHolzer  RPozzi  MDalzell  M Nutritional support via percutaneous endoscopic gastrostomy in children with cardiac disease experiencing difficulties with feeding. Cardiol Young 2002;12 (6) 537- 541
PubMed Link to Article
Hofner  GBehrens  RKoch  ASinger  HHofbeck  M Enteral nutritional support by percutaneous endoscopic gastrostomy in children with congenital heart disease. Pediatr Cardiol 2000;21 (4) 341- 346
PubMed Link to Article
Sheikh  SAllen  EShell  R  et al.  Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest 2001;120 (4) 1190- 1195
PubMed Link to Article
Heuschkel  RBFletcher  KHill  ABuonomo  CBousvaros  ANurko  S Isolated neonatal swallowing dysfunction: a case series and review of the literature. Dig Dis Sci 2003;48 (1) 30- 35
PubMed Link to Article
Durkin  ETSchroth  MKHelin  MShaaban  AF Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I. J Pediatr Surg 2008;43 (11) 2031- 2037
PubMed Link to Article
Meyer  ACLidsky  MESampson  DELander  TALiu  MSidman  JD Airway interventions in children with Pierre Robin Sequence. Otolaryngol Head Neck Surg 2008;138 (6) 782- 787
PubMed Link to Article
Srinivasan  RO’Neill  CBlumenow  WDalzell  AM Perceptions of caregivers following percutaneous endoscopic gastrostomy in children with congenitally malformed hearts. Cardiol Young 2009;19 (5) 507- 510
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Rates of Enteric Feeding in Nonsyndromic and Syndromic Infants
Table Graphic Jump LocationTable 2. Characteristics of the Study Population
Table Graphic Jump LocationTable 3. Incidence of Syndromes and Chromosomopathiesa
Table Graphic Jump LocationTable 5. Comorbidities of Patients With and Without Gastrostomy Tubes
Table Graphic Jump LocationTable 6. Enteric Feeding in Patients With and Without Syndromes and/or Chromosomopathies
Table Graphic Jump LocationTable 7. Enteric Feeding in Patients With 1, 2 or More, and No Major System Comorbidities
Table Graphic Jump LocationTable 8. Comorbidities and Indications for G-Tube Placement in Infants Requiring G-Tubes

References

Cooper-Brown  LCopeland  SDailey  S  et al.  Feeding and swallowing dysfunction in genetic syndromes. Dev Disabil Res Rev 2008;14 (2) 147- 157
PubMed Link to Article
Reid  JReilly  SKilpatrick  N Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 2007;44 (3) 312- 320
PubMed Link to Article
Baudon  JJRenault  FGoutet  JM  et al.  Assessment of dysphagia in infants with facial malformations. Eur J Pediatr 2009;168 (2) 187- 193
PubMed Link to Article
Amstalden-Mendes  LGMagna  LAGil-da-Silva-Lopes  VL Neonatal care of infants with cleft lip and/or palate: feeding orientation and evolution of weight gain in a nonspecialized Brazilian hospital. Cleft Palate Craniofac J 2007;44 (3) 329- 334
PubMed Link to Article
Baujat  GFaure  CZaouche  AViarme  FCouly  GAbadie  V Oroesophageal motor disorders in Pierre Robin syndrome. J Pediatr Gastroenterol Nutr 2001;32 (3) 297- 302
PubMed Link to Article
Evans  AKRahbar  RRogers  GFMulliken  JBVolk  MS Robin sequence: a retrospective review of 115 patients. Int J Pediatr Otorhinolaryngol 2006;70 (6) 973- 980
PubMed Link to Article
Garcez  LWGiugliani  ER Population-based study on the practice of breastfeeding in children born with cleft lip and palate. Cleft Palate Craniofac J 2005;42 (6) 687- 693
PubMed Link to Article
Li  HYLo  LJChen  KSWong  KSChang  KP Robin sequence: review of treatment modalities for airway obstruction in 110 cases. Int J Pediatr Otorhinolaryngol 2002;65 (1) 45- 51
PubMed Link to Article
Lidsky  MELander  TASidman  JD Resolving feeding difficulties with early airway intervention in Pierre Robin sequence. Laryngoscope 2008;118 (1) 120- 123
PubMed Link to Article
Reid  JKilpatrick  NReilly  S A prospective, longitudinal study of feeding skills in a cohort of babies with cleft conditions. Cleft Palate Craniofac J 2006;43 (6) 702- 709
PubMed Link to Article
Smedegaard  LMarxen  DMoes  JGlassou  ENScientsan  C Hospitalization, breast-milk feeding, and growth in infants with cleft palate and cleft lip and palate born in Denmark. Cleft Palate Craniofac J 2008;45 (6) 628- 632
PubMed Link to Article
Smith  MCSenders  CW Prognosis of airway obstruction and feeding difficulty in the Robin sequence. Int J Pediatr Otorhinolaryngol 2006;70 (2) 319- 324
Link to Article
Pagano  MGauvreau  K Principles of Biostatistics.  Belmont, CA Duxbury Press1993;
Chuacharoen  RRitthagol  WHunsrisakhun  JNilmanat  K Felt needs of parents who have a 0- to 3-month-old child with a cleft lip and palate. Cleft Palate Craniofac J 2009;46 (3) 252- 257
PubMed Link to Article
Johansson  BRingsberg  KC Parents' experiences of having a child with cleft lip and palate. J Adv Nurs 2004;47 (2) 165- 173
PubMed Link to Article
Reid  J A review of feeding interventions for infants with cleft palate. Cleft Palate Craniofac J 2004;41 (3) 268- 278
PubMed Link to Article
Masarei  AGSell  DHabel  AMars  MSommerlad  BCWade  A The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants. Cleft Palate Craniofac J 2007;44 (3) 321- 328
PubMed Link to Article
Karayazgan  BGunay  YGurbuzer  BErkan  MAtay  A A preoperative appliance for a newborn with cleft palate. Cleft Palate Craniofac J 2009;46 (1) 53- 57
PubMed Link to Article
Peters  RTBalduyck  BNour  S Gastrostomy complications in infants and children: a comparative study. Pediatr Surg Int 2010;26 (7) 707- 709
PubMed Link to Article
Rio  AEllis  CShaw  C  et al.  Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease. J Hum Nutr Diet 2010;23 (4) 408- 415
PubMed Link to Article
Sullivan  PB Gastrointestinal disorders in children with neurodevelopmental disabilities. Dev Disabil Res Rev 2008;14 (2) 128- 136
PubMed Link to Article
Godbole  PMargabanthu  GCrabbe  DC  et al.  Limitations and uses of gastrojejunal feeding tubes. Arch Dis Child 2002;86 (2) 134- 137
PubMed Link to Article
Saenz  RBBeebe  DKTriplett  LC Caring for infants with congenital heart disease and their families. Am Fam Physician 1999;59 (7) 1857- 1868
PubMed
Ciotti  GHolzer  RPozzi  MDalzell  M Nutritional support via percutaneous endoscopic gastrostomy in children with cardiac disease experiencing difficulties with feeding. Cardiol Young 2002;12 (6) 537- 541
PubMed Link to Article
Hofner  GBehrens  RKoch  ASinger  HHofbeck  M Enteral nutritional support by percutaneous endoscopic gastrostomy in children with congenital heart disease. Pediatr Cardiol 2000;21 (4) 341- 346
PubMed Link to Article
Sheikh  SAllen  EShell  R  et al.  Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest 2001;120 (4) 1190- 1195
PubMed Link to Article
Heuschkel  RBFletcher  KHill  ABuonomo  CBousvaros  ANurko  S Isolated neonatal swallowing dysfunction: a case series and review of the literature. Dig Dis Sci 2003;48 (1) 30- 35
PubMed Link to Article
Durkin  ETSchroth  MKHelin  MShaaban  AF Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I. J Pediatr Surg 2008;43 (11) 2031- 2037
PubMed Link to Article
Meyer  ACLidsky  MESampson  DELander  TALiu  MSidman  JD Airway interventions in children with Pierre Robin Sequence. Otolaryngol Head Neck Surg 2008;138 (6) 782- 787
PubMed Link to Article
Srinivasan  RO’Neill  CBlumenow  WDalzell  AM Perceptions of caregivers following percutaneous endoscopic gastrostomy in children with congenitally malformed hearts. Cardiol Young 2009;19 (5) 507- 510
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,738 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Rates and risks of gastrostomy tubes in infants with cleft palate. Arch Otolaryngol Head Neck Surg 2011;137(3):275-81.
Jobs