Lower respiratory tract infections in children with severe neurodisability are usually caused by aspiration of stomach contents from gastroesophageal reflux (GOR) or direct aspiration (DA) of food due to oral and pharyngeal motor problems. To determine the contributions and interactions of GOR and DA, oesophageal 24-hour pH monitoring and feeding videofluoroscopy were performed in 34 children (age range 7 months to 16 years, mean 7 years) who had severe physical and learning disabilities and who were slow feeders. Subjects were divided into three groups according to the frequency of their respiratory tract infections. Subjects in group 1 had no respiratory tract infections (N=10); five had GOR and none had DA. Subjects in group 2 had minor respiratory tract infections but had not received more than one course of antibiotics for this in the previous year (N=8); two had GOR alone, four had DA alone, and two had neither. All subjects in group 3 had recurrent respiratory tract infections (N=16); one had GOR alone, seven had DA alone, and eight had both GOR and DA. This study suggests that oral and pharyngeal motor problems are the major cause of respiratory tract infection in children with severe neurodisability. These problems lead to DA and, if GOR is present, to the aspiration of stomach contents. Those children with both DA and GOR are more likely to have severe respiratory tract infections which may lead to gastrostomy feeding (together with fundoplication). GOR without sufficient oral and pharyngeal motor problems to cause DA is less likely to cause respiratory tract infection in children with severe neurodisability.

Individuals with neurodisability and dysphagia often aspirate food because of oropharyngeal impairments and poor control of respiration. This study explored the interaction between these factors in 32 participants aged 3-33 years. Each person underwent a modified barium swallow study, during which respiration was recorded and displayed simultaneously on the video screen, in terms of inspiration, expiration, and velocity of airflow (TV data). The duration of time that material remained in the pharynx before the swallow (either because of pharyngeal delay or residue from the previous swallow) was called the pharyngeal dwell time (PDT). The mean PDT of the 5 slowest swallows for each participant was calculated for both liquids and thick purees. The proportions of time spent in inspiration and expiration during the PDT in seconds and a score representing the abnormality of inspiration, including its frequency and velocity, were recorded. The volume of material in the pharynx prior to these swallows was also estimated. Twelve participants aspirated liquids and 3 of the 12 also aspirated thick purees. PDTs were longer among aspirators (6.2 s) than nonaspirators (2.4 s) when consuming liquids. Also, the percentage of the PDT spent in inspiration was greater among aspirators than nonaspirators when taking liquids (31% vs. 11%) or thick purees (35% vs. 14%). During the PDT, aspirators showed more abnormal respiratory patterns for liquids but not for purees. There were no differences in the volumes of liquid or puree in the pharynx before the swallow between aspirators and nonaspirators. A plot of the PDT against a combined respiratory impairment score (i.e., percentage of the PDT spent in inspiration and respiratory abnormality) predicted aspirators with a sensitivity of 83% and specificity of 95%. Aspiration results from oropharyngeal impairments with inadequate respiratory integration. Further research is needed to investigate whether intervention to improve respiratory control can reduce aspiration in people with dysphagia.

Aim  The pelvic radiograph in children with cerebral palsy (CP) can inform the degree of hip displacement by calculation of the migration percentage. However, concerns have arisen about the reliability of this measurement. The present study examined the reliability of radiographic assessment of displacement and the importance of positioning and reporting experience. Method  Two pelvic radiographs, taken at least an hour apart, were performed in 20 children (total 40 hips) in the standard position by a trained paediatric radiographer. Children (13 males, seven females) were aged 30 months to 10 years with severe bilateral spastic CP in Gross Motor Function Classification System levels IV (n=10) and V (n=10). The migration percentage of each hip was measured on two occasions 3 months apart by two experienced radiologists independently. Comparisons of migration percentage were made in three ways by (1) the same observer at the same time, (2) the same observer 3 months apart, and (3) different observers 3 months apart. Results  Migration percentage (mean [SD]) was (1) 3.2% (3.5), (2) 3.3% (3.2), and (3) 3.7% (3.8) respectively. Interpretation  Reliable measures of migration percentage can be obtained with correct positioning and if reported by suitably experienced radiologists, making this a valid surveillance method. Clinical decisions can be made taking into account an expected error in hip displacement measurements.

E4 to Table I: Details of subjects