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Nissen Fundoplication

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Question

Three-week-old girl had a Nissen Fundoplication. Now, at two years of age, she is currently tube fed with Pediasure. Her family is hoping to start the transition to oral feedings. Current medications include Prevacid and doctor wants to begin Reglan when diarrhea subsides. The child's mother is concerned that her daughter went through a growth spurt early on and has had little growth since

1 - What formulas are recommended for individuals with CdLS other than Pediasure

2 - What pureed foods can be offered for variety

3 - Are there long-term nutritional suggestions to encourage growth/thriving

4 - Should her mother be concerned or take action in regard to current growth retardation

5 - Is it common to have a growth spurt and then stop

6 - Doctor is considering a Nissen redo. Is there a clue to determine when a wrap has failed in a child who has always been able to vomit past the wrap

7 - Would they benefit from an open Nissen rather than a Laparoscopic so it will not fail again

8 - What does Reglan do? Is it safe?

Answer of our experts

This child may need a second opinion. It is not really in her best interest to answer so many complicated and intertwined questions without seeing the record and the child. In general, when a child is not growing, there is a need for more calories. Pediasure is fine, but occasionally one formula works better than another. Pureed foods are fine, but have less nutritional value than pediasure. A growth curve should not stop and start. Was the initial fundoplication laparascopic? A redo cannot be done laparoscopically, generally. There is scar tissue. Fundoplications done early by any technique may not last for years. There are many inter-related problems here, and they should really be addressed directly. Anything less will potentially hurt her. The first step would be to schedule a sit-down session with their gastroenterologist and their surgeon, and discuss the issues and these questions

DP/TK 7-13-10

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Recommendation(s)

Feeding and Dental Difficulties

R12
In every CdLS individual with prolonged and marked feeding difficulties, the multidisciplinary assessment (from healthcare workers across many disciplines) should consider (temporary) placement of a gastrostomy (surgical opening through the abdomen into the stomach) as a supplement to oral feeding.
R13
In individuals with CdLS who have recurrent respiratory infections, reflux and/or aspiration (breathing foreign objects into airways) should be ruled out.
R14
The palate should be closely examined at diagnosis. In case of symptoms of a (submucous) cleft palate, referral for specialist assessment is indicated.
R15
Dental assessment and cleaning should take place regularly; a more thorough dental examination or treatment under anaesthesia may be necessary.

Recommendation(s)

Reflux

R32
Consider always gastro-oesophageal reflux disease (GORD) in any individual with CdLS owing to its frequency and wide variability in presentation, which includes challenging behaviour.
R33
Modification of nutrition and proton pump inhibitors (PPI) are the first-line treatments of GORD. Anti-reflux medications need to be used to their maximum dosage. Surgical interventions for GORD should be limited to those individuals with CdLS in whom nutritional and medical treatments have been unsuccessful or airway safety is at risk.
R34
If GORD symptoms persist, endoscopy should be strongly considered whilst an individual with CdLS is still in paediatric care.
R35
Surveillance for Barrett’s Oesophagus needs to be discussed with and decided together with the family, balancing the potential gain in health and burden for the individual with CdLS.

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