Table 2

Summary of reviewed studies; case series

First author and date	Method	Participants	Recruitment period	Intervention	Length of follow up	Outcome
CP, cerebral palsy; GOR, gastro-oesophageal reflux; PEG, percutaneous endoscopic gastrostomy; ARP, antireflux procedure; usually Nissen fundoplication.
Shapiro⁵⁷ 1986	Retrospective	19 children with severe disability.	Gastrostomy done 1981 onwards.	Gastrostomy, (+ ARP in 5).	Mean: 2 years.	GOR: 5 had persistent vomiting after gastrostomy. 2 underwent ARP.
		14 with CP.			Range: 6 months to 41 months.	Growth: weight, increased and 16 increased their weight/length ratio.
		Mean age: 5 years.			Lost: none.	Death: none.
		Range: 5 months–14 years.				Other: major complications, none reported.
Rempel¹⁹ 1988	Retrospective and prospective.	57 children with CP.	Gastrostomy, 10 done during 1968–83, rest later.	Gastrostomy, (+ ARP in 24).	Mean: 3.4 years.	GOR: 8/33 symptomatic after gastrostomy and underwent ARP. 6/24 underwent further surgery for GOR (4 revision of ARP, 2 feeding jejunostomies).
		Mean age: 10.7 years.			Range: 3 months to 18.3 years.	Growth: weight, 24/35 accelerated gain. length, 8/35 accelerated gain.
		Range: 9 months–23 years.			Lost: 22 did not have pre and post gastrostomy measures of growth.	Death: 8 (5 within 1 year of surgery).
						Other: major complications, 13/57, including gastrointestinal bleeding and ulceration (5), peritonitis (3), other (5). Caregiver satisfaction, ease of feeding, improvement in child’s disposition and nutrition were main advantages for the majority.
Sanders⁵⁸ 1990	Retrospective	51 children with CP.	Children referred to clinic during 1980–86.	Gastrostomy in 47 (+ ARP in 44).	Mean: 2.4 years.	GOR: 5 symptomatic GOR after gastrostomy with ARP.
		Mean age: not stated.		4 fed only by nasogastric tube	Range: 6 months to 5.5 years.	Growth: weight, improved in all but 1. Length, minimal change overall.
		Range: 3 months–15.5 years.			Lost: none	Death: 7/51.
						Other: reports of improved alertness and less irritability in some children.
McGrath⁵⁹ 1992	Retrospective and prospective	61 children with CP.	Gastrostomy done 1984–89.	Gastrostomy (+ ARP in 57).	Mean: 2.4 years.	GOR: 9 symptomatic GOR after gastrostomy with ARP.
		Mean age: not stated.			Range: 1 month to 6.5 years.	Growth: not reported.
		Range: 17 years or less.			Lost: 1, 6 months after surgery.	Death: 16/60, 14 died within 2 years of gastrostomy (14 respiratory related).
						Other: 20/60 children had 32 complications within the 1st week after gastrostomy- respiratory (21), other (11). 29 children had 36 late complications including paraoesophageal/hiatal hernias (8), small bowel obstruction (7), retching vomiting and dumping syndrome (15), respiratory (7), wound infection (2). 20 children underwent further surgery, 13 once and 7 twice. Caregiver satisfaction: 53/57 caregivers polled were pleased with the gastrostomy and 55/57 said child’s comfort and abilities were enhanced.
Lewis³³ 1994	Prospective	10 children with CP.	Not stated.	PEG with aggressive enteral feeding regimen.	Mean: 8.4 months.	GOR: 1 underwent ARP for GOR soon after gastrostomy. 3/9 who achieved the nutritional target after gastrostomy got worse GOR when antireflux medication was stopped, 1 underwent ARP. 6 improved and remained off antireflux medication.
		Mean age: 9.1 years.			Range: 2 months to10 months.	Growth: weight, 9/10 gained and triceps skinfold thickness reached target (>50th centile for age).
		Range: 4–13 years.			Lost: none.	Death: not reported.
						Other: major complications, not reported.
Isaacs⁶⁰ 1994	Retrospective and prospective.	22 children with severe neurological disability. 15 with CP.	Not stated.	Gastrostomy.	Mean: not stated.	GOR: not reported.
		Mean age: not stated.		⩾ 50% of total energy intake via gastrostomy.	Range: 10 months to 4 years.	Growth: weight, 21/22 gained
		Range: 2–12 years.			Lost: none.	Length, 9/22 gained by first check following gastrostomy (exact timing not stated). Subsequent measures: 11 increased weight z scores
						Death: not reported.
						Other: not reported.
Borowitz⁶¹ 1997	Prospective	19 children with severe neurological disability. 14 with CP.	PEG done between 1991–93.	PEG.	Mean: 20.7 months.	GOR: 2 children had increased vomiting after PEG (1 new, 1 worse). 7 children had less vomiting. None underwent ARP after PEG insertion.
		Mean age: 33.6 months.			Range: 7 months to 33 months.	Growth: not reported.
		Range: 1.5 months–13.1 years.			Lost: none.	Death: none reported.
						Other: 2 had more respiratory infections after PEG and 5 had less.
						Caregiver satisfaction, 17 reported less stress. 19 would recommend PEG to other families.
Bachrach⁶² 1998	Retrospective	101 children with	PEG done between 1991–1997.	PEG.	Mean: not stated.	GOR: within 6 months post PEG, 44 had new or worse
		Severe neurological disability. Mainly CP.			Range: not stated.	GOR, 11 of whom had an acute hospital admission (7 with pneumonia). 13 underwent further surgery for GOR
		Mean age: not stated.			Median: 6 months (all followed for at least 6 months).	Growth: not reported.
		Range: 3 months–20 years.			Lost: none.	Death: none associated with PEG tube placement.
						Other: technical complications included failure to place PEG (2), gastrocolic fistula (1), tract dehiscence at 1st PEG tube change (4). 9% had site infections.
Commisso⁶³ 1998	Retrospective	77 children with CP.	Gastrostomy done between 1992–97.	Gastrostomy.	143.1 person years.	GOR: not reported.
		Mean age: 5.4 years.		PEG in 32, surgical gastrostomy alone in 20, gastrostomy +ARP in 25.	Lost: none reported.	Growth: not reported.
		Range: <18 years at surgery.				Death: 7/77.
						Other: not reported.
Sulaeman⁶⁴ 1998	Retrospective	85 children, 79 with neurological disability. 63 with CP.	PEG done 1990–1995.	PEG.	Mean: not stated.	GOR: 8 underwent ARP for worsening GOR
		Mean age: 7 years.			Range: 1 year to 4 years.	Growth: weight, increased in 81children, (z score for weight p<0.001) at 6 and 12 months.
		Range: 1 month–22 years.			Lost: none reported.	Death: none related to procedure, other deaths not stated.
						Other: major complications requiring further surgery in 2: separation of the abdominal wall and severe infection with tube migration. 14 children had minor complications, acutely post PEG, wound infection (6), site problems (7), tube migration (1). Longer term complications not reported.
Brant⁶⁵ 1999	Prospective	20 children with neurological impairment, 16 with CP.	Gastrostomy done 1996–1997.	PEG.	Mean: 5.7 months.	GOR: 3 had symptoms of GOR after PEG.
		Mean age: 6.5 years.			Range: 2 months to 10 months.	Growth: weight, z scores increased after PEG (p<0.01).
		Range: 8 months–15 years.			Lost: none reported.	Length, z scores for length, height/weight ratio, and height/age ratio unchanged.
						Death: not reported.
						Other: complications 18, including tube replacement (3), granulations (7), ostomy infection (7), pneumoperitonitis (1).
Duncan⁶⁶ 1999	Retrospective	19 children with CP.	Not stated.	Gastrostomy. Entire nutrition via gastrostomy with commercially prepared formula and supplements.	Mean: not stated.	GOR: not reported
		Mean age: not stated			Range: not stated.	Growth: not reported.
		Range: 28 months–18 years.			Lost: none.	Death: not reported.
						Other: 10 were osteopenic (radiological diagnosis).
						5 had fractures without significant trauma.
						13 received <50% of recommended caloric intake. Minerals and micronutrients were also deficient compared with recommended daily intake and included calcium, phosphorus, vitamin D, iron, copper, zinc, and magnesium.
						18/19 received excess folic acid and vitamin B 12.
Smith²⁰ 1999	Retrospective and prospective.	41 children with CP in the prospective study group.	Gastrostomy or jejunostomy done 1990–98	Gasrostomy or jejunostomy.	Mean: 3.5 years.	GOR: 14/27 continued symptoms of GOR after gastrostomy with ARP.
		Mean age: 5.0 years.		(+ ARP in 27)	Range:0 to 8 years	Growth: not reported
		Range: 2months–18 years.			Lost: 1.	Death: not reported separately for study group.
						Other: major complications (8) including volvulus, prolapse, bowel obstruction, ulceration, gastrointestinal bleeds and peritonitis; minor (38/40 children affected) problems included diarrhoea and constipation, blocked tube, site infections and leakage.
						Caregiver satisfaction: 32/40 stated positive impact on family life, child’s mood improved (8). 11 had problems with family functioning and stress.
Sullivan⁶⁷ 2002	Prospective	Primary caregivers of 50 children with CP.	Not stated.	Gastrostomy	Mean: not stated.	GOR: not reported
					Range: not stated.	Growth: not reported.
					Seen at 6 months and 12 months.	Death: not reported.
					Lost: 23 at 12 months.	Other: scores on SF 36 (version II) showed improvement in all domains at 12 months post gastrostomy. The social function score was lower at 6 months than before gastrostomy but higher at 12 months. No tests of significance given.
Sullivan⁶⁸ 2002	Prospective	55 children with CP.	Not stated.	Gastrostomy	Mean: not stated.	GOR: not reported.
		Mean age: 5.7 years.			Range: not stated.	Growth: weight, increased over 12 months, mean:33%, range: 6.5–80%
		Range not stated.			Seen at 6 months and 12 months.	body fat, increase in 1st. 6 months mean: 4% (95% CI = 1.4–6.5) p = 0.004.
					Lost: not stated.	Death: not reported.
						Other: complications not reported nutrition, increase in mean intake of energy (p = 0.05) general health, apparently fewer chest infections and fewer hospital admissions for chest infections.
						Growth: weight, increased over 12 months, mean: 33%, range: 6.5–80% body fat, increase in 1st. 6 months mean:4% (95% CI = 1.4–6.5) p = 0.004.
						Death: not reported.
						Other: complications not reported nutrition, increase in mean intake of energy (p = 0.05) general health, apparently fewer chest infections and fewer hospital admissions for chest infections.