If your child still cannot swallow her food safely despite these conservative measures, she might require surgery.
The surgery may involve removing any obstructions that may be preventing the food from going down properly or putting in a feeding tube that allows you to put food directly into her stomach.
Putting in a feeding tube ensures that your daughter gets all the nutrients required for her to grow and thrive.
Q: My four-year-old has cerebral palsy and has multiple problems related to feeding. First, she cannot swallow her food properly — she constantly chokes and cries. Whatever little she manages to eat, she vomits almost half of it. Subsequently, she is much smaller than her peers (looks like a two-year-old). She has also been admitted in hospital multiple times with chest infections, which her doctor says, occur due to her vomiting (I still do not understand how the two are related). Her paediatrician explained that the vomiting is actually reflux and due to its severity, she needs surgery. I have resisted the idea for over a year now but none of the medication we have been giving her seem to work. At four years old, is it safe for my child to undergo major surgery? What exactly does surgery for reflux involve? Will the surgery sort out her choking problem? Will she continue to use medication?
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A: Cerebral palsy comes with a number of challenges and it is not unusual for the children to have feeding problems. The mental and physical capacity of these children does not improve significantly as they age, so it is important to deal with the feeding problems early in life.
Cerebral palsy and swallowing problems
A large number of children with cerebral palsy have swallowing problems. Parents often report that the child either chokes or coughs a lot during feeding. In addition, most children have persistent drooling.
Several feeding techniques have been known to reduce this issue. A speech therapist can show you a few tips on how to improve your child’s swallowing. You might also have to purée your child’s feeds and thicken liquids to help make swallowing easier.
If your child still cannot swallow her food safely despite these conservative measures, she might require surgery. The surgery may involve removing any obstructions that may be preventing the food from going down properly or putting in a feeding tube that allows you to put food directly into her stomach. Putting in a feeding tube ensures that your daughter gets all the nutrients required for her to grow and thrive.
What causes reflux?
Gastroesophageal reflux occurs when the opening to the stomach (known as lower oesophageal sphincter) does not close properly. This causes food and stomach digestive juices to rise up the food pipe and in severe cases, comes out of the mouth as ‘vomit’.
Reflux also causes symptoms of heartburn and it is not unusual to have children complain of pain in the belly or chest. The child may also develop a hoarse voice, bad breath and tooth delay. Severe reflux is also associated with recurrent chest infections (usually mistaken for asthma) and failure to thrive (malnourishment).
Reflux, swallowing problems and chest infections: a dangerous triad
Children who have swallowing problems or severe reflux sometimes have food particles or ingested fluids accidentally going into their windpipes (a process known as ‘aspiration’). Once feeds get into the lungs, the child is at great risk of developing chest infections. This can, sometimes, be fatal.
Children with cerebral palsy are unable to efficiently protect their airway from food entry during swallowing and during reflux — this puts them at significant risk of aspiration and subsequent chest infections.
Surgery
Your child will likely need a surgical procedure known as a fundoplication. In most cases, the procedure can be done laparoscopically (key hole surgery with a camera) or using the traditional ‘open’ method (where the surgeon makes a larger cut on your child’s belly). During this procedure, the surgeon wraps the top of the stomach on to the food pipe.
The food pipe passes through a muscular sheet that separates the chest cavity from the abdomen known as the diaphragm. The hole through which it passes may need to be narrowed to ensure that the reflux is well controlled. If your child cannot safely swallow, a feeding tube may be inserted into the stomach during the operation.
What are the surgery risks, complications?
Anesthetic:The procedure is performed under general anaesthesia and on average takes two to four hours to perform. There are known risks of anaesthetic drugs and your child will require a pre-operative check-up to assess whether or not she is capable of handling general anaesthesia. All centres in Kenya that carry out fundoplication have anaesthetists who are well versed in managing children.
Surgical complications: This include bleeding, infection and accidental damage to the stomach, food pipe or intestines. These will be discussed in-depth by the surgeon.
Recurrence of reflux: Sometimes, children who have had this procedure develop reflux again several years after the procedure. This is because the section of the stomach that was attached to the food pipe unwraps. Usually, this requires repeat surgery.
Wrap becomes ‘too tight’: In some cases, the stomach may be wrapped too tightly around the food pipe, which narrows the channel through which food passes making it difficult to feed. In this case, the channel can be widened by dilating it regularly in hospital.
Bloating: After the procedure, some children develop bloating, as they are not able to pass out gas easily. This usually improves with time. Some children also routinely retch and are unable to vomit but this too, resolves with time.
Reduced stomach capacity: If your daughter does not have a feeding tube inserted, you may notice that she is unable to take large quantities of food in one sitting. If this is the situation, give her small regular feeds. Ask a nutritionist to help you design a good feeding plan for her (especially since she is currently malnourished).
Medication
Most children are in a position to get off their reflux medication after the surgery. However, in cases where the wrap is loose, the child may need to continue with the medication.
