This study included 34 patients with severe neurological impairment who underwent PEG tube insertion to evaluate symptoms of gastrointestinal dysfunction between those fed peptide or casein-based formulae.

There were two groups of patients involved: 17 received a peptide-based formula (Group A), and 17 received a casein-based formula (Group B). Neurologically challenged children with severe gastrointestinal dysfunction symptoms require nutritional adjustments in their enteral formula [14]. In Group A, the majority of patients (64.7%) were female, with a mean age of 4.1 years ± 3.1 (ranging from 2 to 13 years), while in Group B, the majority (70.6%) were male, with a mean age of 4.7 years ± 3.4 (ranging from 2 to 12 years). This contrasts with Katz et al.'s 2024 [15] review of children with severe neurological impairment and gastrointestinal dysfunction, where males were predominant.

A systematic review of pediatric patients with P.E.G. revealed that the most common complications were reoperation (2.64%—12.4%) and gastrocolic fistula/perforation (0.9%—3.8%) [16]. In contrast, our study found that infection at the P.E.G. tube insertion site was the most common complication, occurring in 7 patients (20.5%), followed by granuloma at the insertion site in 5 patients (14.7%).

The 24-h recall approach obtained from parent/caregiver was used in this study to assess dietary intake. Poor swallowing ability with tube dependency and limited oral intake was recorded in 94.1% of cases, while 5.9% had an oral intake of a single consistency requiring special meal preparation. In contrast, the study conducted by Lopes and colleagues in 2013 [17] on the dietary patterns of 90 children with cerebral palsy found difficulty chewing solid food in 26% of cases and difficulty swallowing in 9%.

Patients in Group A in our study showed a statistically significant improvement in swallowing ability six months after P.E.G. tube insertion compared to pre-insertion (p-value = 0.002). Seven patients (41.2%) were tube-dependent with minimal/inconsistent oral intake, whereas 10 patients (58.8%) had a full oral intake of a single consistency requiring special preparation. These patients showed a statistically significant reduction in choking/coughing episodes per week and aspiration pneumonia requiring hospital admission six months after P.E.G. tube insertion compared to pre-insertion (p-value = 0.000).

Patients in Group B showed a statistically significant reduction in choking/coughing episodes per week and aspiration pneumonia requiring hospital admission six months after P.E.G. tube insertion compared to pre-insertion, with p-values of 0.014 and 0.016, respectively. However, there was no statistically significant difference in swallowing ability in this group pre- and six months post-PEG insertion. Dipasquale and colleagues (2020) [18] recommend a high-energy density formula with fiber, glucose polymers, and/or long-chain triglycerides for children with increased caloric needs or poor tolerance of large feeding volumes. No studies have compared peptide-based and casein-based formulas for improving symptoms of oropharyngeal dysfunction.

Our study showed a statistically significant improvement in pain and irritability symptoms six months after P.E.G. tube insertion compared to baseline in both Group A and Group B, with p-values of 0.008 and 0.016, respectively. These results are consistent with Savage et al. (2012) [19], who found no significant difference in overall pain levels between casein and whey formulas.

Additionally, there was a significant improvement in constipation in Group A. This finding aligns with Minor and colleagues (2016) [20], who observed an improvement in constipation (43%, n = 7) in 13 patients fed via gastrostomy tube after switching from whole protein to whey-based formula. In contrast to our study, they reported an improvement in diarrhea (100%, n = 3) after switching to the whey-based formula.

Mohamed Elfadil and colleagues (2022) [21] reported that peptide-based formula may benefit children with poor feeding tolerance due to delayed gastric emptying. Similarly, Alexander and colleagues (2016) [22] observed that whey-based enteral formula significantly reduced acid gastroesophageal reflux episodes in children with severe neurological impairment and reduced gagging and retching in these patients. These findings align with our study, where a statistically significant reduction in reflux and vomiting episodes was observed six months after P.E.G. tube insertion in Group A compared to pre-insertion (p-value = 0.034). No statistically significant difference was found in Group B.

At baseline, patients in Group A had a median weight of 7.5 kg, with 52.9% falling below the 5th percentile on weight-for-age charts. The median stature was 71 cm, with 41.2% falling between the 10th and 25th percentiles on stature-for-age charts. The median BMI was 14.9, with 35.3% falling between the 10th and 25th percentiles on BMI-for-age charts. In Group B, the median weight was 8 kg, 52.9% below the 5th percentile on weight-for-age charts. The median stature was 72 cm, with 41.2% between the 5th and 10th percentiles on stature-for-age charts. The median BMI was 15.8, with 47.1% between the 25th and 50th percentiles on BMI-for-age charts. In comparison, Suh et al. (2020) [23] found a median weight of 37.83 kg, a median stature of 59.3 cm, and a median BMI of 11.64 before P.E.G. insertion.

Novak and colleagues (2024) [14] reported that P.E.G. feeding is a reliable and effective technique for feeding infants, children, and adolescents, promoting long-term growth, nutritional catch-up, and improving quality of life for both child and caregiver. Our findings align with this, as six-month follow-up anthropometric measures in Group A showed a statistically significant improvement in weight and weight-for-age percentile (p-value = 0.000), with 47.1% now between the 25th and 50th percentiles on weight-for-age charts. A statistically significant improvement in stature was observed (p-value = 0.000), though there was no difference in stature-for-age percentile, with 35.3% between the 10th and 25th percentiles. BMI and BMI-for-age percentile significantly improved, with 41.2% between the 75th and 90th percentiles (p-value = 0.000).

In Group B, a six-month follow-up showed a statistically significant improvement in weight and weight-for-age percentile (p-value = 0.000), with 58.8% between the 10th and 25th percentiles. Stature improved significantly (p-value = 0.000), though no change was observed in stature-for-age percentile, with 47.1% between the 5th and 10th percentiles. BMI and BMI-for-age percentile significantly improved, with 64.7% between the 75th and 90th percentiles (p-value = 0.000).

Sullivan et al. (2005) [24] found that anthropometric measurements in children with cerebral palsy improved between six and twelve months following P.E.G. tube placement, with no significant complications. They reported that swallowing capacity, discomfort, irritation, and constipation significantly improved in children with spastic quadriplegia, though similar improvements were not seen in children with flaccid muscle tone. Our study's limited sample size for flaccid cases (6 children) prevented statistical significance from being established in these patients.

In their 2020 research, Jesus and Stevenson [25] found that hypertonic children often experience difficulties with swallowing due to increased muscular tone, making feeding particularly challenging. We hypothesize that the true nutrient absorption in these children is less than the total food intake. The insertion of a P.E.G. tube may have improved actual nutritional intake, which appears to be a significant factor in the observed improvements in anthropometric measurements and nutritional status in hypertonic children. This likely contributed to enhanced chewing ability and reduced gastrointestinal dysfunction symptoms.

However, our study is limited by a small sample size and a short follow-up period. Future research should focus on larger sample sizes and longer follow-up durations to evaluate progress more accurately. Only after such studies could the potential for gastrostomy tube removal be considered.

To gain a more accurate assessment of the nutritional status of children with severe neurological impairment, future studies should analyze specific micronutrient levels, such as vitamin C, zinc, and iron, in addition to anthropometric measures like fat mass and bone mineral density.