title: Gastroesophageal reflux and behavior in neurologically impaired children.
abstract: OBJECTIVE
  This study aimed to evaluate a possible link between gastroesophageal reflux (GER) and behavior pattern indicating pain experience in a group of children with severe neurologic deficits.
  
  
  METHODS
  We prospectively evaluated 19 patients with severe neurologic impairment (10 males and 9 females; mean age, 12.7 years) suspected for GER before and after initial treatment. Repeated 24-hour pH monitorings were performed in 19 children, whereas additional repeated endoscopic investigations were carried out in 18. In these children a histologic examination of mucosal biopsies was performed. Behavior pattern was described by parents or caregivers. The level of activity was classified as no/occasional agitation, daily agitation, and autoaggressive behavior.
  
  
  RESULTS
  The behavioral pattern of the children was most frequently (n = 24) described as "agitated" followed by "autoaggressive" behavior (n = 10). Neither autoaggression nor agitation was less frequent (n = 4). Children with autoaggressive behavior had a significantly higher reflux index compared with the neurologically impaired patients with agitation only (P < .01). The reflux index was significantly higher in children with behavioral abnormalities than in children without abnormalities (P < .0004). In children without agitation or autoaggression, the pH measurements were all normal. Biopsies of esophageal mucosa revealed inflammation in 27 cases (first degree in 9; second degree in 12, and third degree in 6). Patients with autoaggressive behavior and those with agitation only had a significantly higher degree of inflammation compared with children without behavioral abnormalities (1.77 and 1.35 vs 0.25, respectively; P < .05). The degree of inflammation did not differ significantly among children with behavioral abnormalities.
  
  
  CONCLUSIONS
  The present study suggests that in children with severe neurologic impairment, autoaggressive behavior or considerable agitation may be a marker for reoccurring or first-time-diagnosed pathologic GER. The severity of reflux correlates significantly to the behavior pattern resulting from experiencing pain. Pathologic GER should be excluded in all neurologically impaired children with behavioral abnormalities to prevent reflux-related complications and improve health-related quality of life.
authors.affiliation: Department of Pediatric Surgery, University of Graz, Medical School, 8036 Graz, Austria. aljagoessler@yahoo.com
authors.forename: Alja
authors.initials: A
authors.lastname: Gössler
authors.forename: Johannes
authors.initials: J
authors.lastname: Schalamon
authors.forename: Andrea
authors.initials: A
authors.lastname: Huber-Zeyringer
authors.forename: Michael E
authors.initials: ME
authors.lastname: Höllwarth
mesh_terms: D000374:Aggression; D002648:Child; D002652:Child Behavior; D050782:Esophageal pH Monitoring; D004945:Esophagoscopy; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D008607:Intellectual Disability / Q000150:complications*; D008297:Male; D011595:Psychomotor Agitation / Q000150:complications; D012652:Self Mutilation