How Does Surgery for Esophageal Atresia Affect Children's Attention and Cognition?

What you need to know

• Children born with esophageal atresia who undergo minimally invasive surgery are at higher risk for attention problems at school age compared to those who have open surgery.
• Overall intelligence and school performance were normal in children with esophageal atresia, but over 50% showed impairment in one or more neurocognitive areas.
• Lower socioeconomic status was also associated with attention problems and other cognitive difficulties in these children.

Understanding esophageal atresia

Esophageal atresia is a birth defect where the esophagus (the tube that connects the mouth to the stomach) does not develop properly. Instead of forming a continuous passage, it ends in a pouch, preventing food from reaching the stomach. This condition requires surgical correction soon after birth to allow the baby to feed normally.

Traditionally, this surgery was performed through an open incision in the chest. In recent years, many centers have adopted minimally invasive surgical techniques using small incisions and a camera. While this approach may have some benefits, there are concerns about its effects on brain development in newborns.

The study: Assessing long-term cognitive outcomes

Researchers from the Erasmus Medical Centre in the Netherlands conducted a study to examine how children born with esophageal atresia fare cognitively at school age. They were particularly interested in whether the type of surgical approach (open vs. minimally invasive) had any impact on cognitive outcomes.

The study included 65 children with an average age of 8 years who had undergone surgery for esophageal atresia as newborns. These children underwent extensive cognitive testing as part of a long-term follow-up program.

Key findings

Overall intelligence and school performance

The good news is that children in the study showed normal intelligence scores and the majority (68%) attended regular education without needing extra support. This suggests that many children with esophageal atresia develop typically in terms of overall cognitive ability.

Attention difficulties

However, the study revealed that many children experienced difficulties with attention. Specifically:

• The speed at which children could maintain attention on a task was below average.
• Children showed greater fluctuations in their attention compared to typical peers.
• Over 50% of the children showed impairment (scoring very low) on at least one cognitive test, with attention being the most frequently affected area.

Factors associated with attention problems

Two key factors were associated with a higher risk of attention problems:

1. Minimally invasive surgery: Children who underwent the minimally invasive surgical approach were more likely to have attention difficulties compared to those who had open surgery.

2. Lower socioeconomic status: Children from families with lower socioeconomic status (based on maternal education level) were also at higher risk for attention problems.

Why might minimally invasive surgery affect attention?

The researchers propose several potential reasons why minimally invasive surgery could impact brain development and attention:

1. Longer duration: Minimally invasive procedures often take longer to perform than open surgery, potentially exposing the newborn’s brain to anesthesia for a greater time.

2. Technical challenges: The minimally invasive approach is more technically demanding, which could lead to periods of suboptimal oxygenation or blood flow during the procedure.

3. CO2 exposure: To create space for the surgical instruments, the chest cavity is inflated with carbon dioxide gas during minimally invasive surgery. This can lead to increased CO2 levels in the blood (hypercapnia) and increased acidity (acidosis), which might affect the developing brain.

It’s important to note that surgical techniques and anesthesia management have likely improved since the children in this study underwent their operations. The long-term effects of current practices may differ.

Other cognitive findings

While attention was the most significantly affected area, the study found some other cognitive domains where children scored slightly below average:

• Visuospatial memory: The ability to remember and manipulate visual and spatial information.
• Planning: A component of executive function related to organizing and sequencing actions.

These difficulties were generally mild, and many children still performed within the normal range.

Implications for families and healthcare providers

This research highlights the importance of long-term follow-up for children born with esophageal atresia. While many of these children do well overall, there is a risk of subtle cognitive difficulties, particularly in the realm of attention.

For parents and caregivers:

• Be aware that your child may face challenges with sustained attention as they grow older.
• Consider discussing any concerns about attention or learning with your child’s doctor or teachers.
• Early intervention and support can be helpful if attention problems do emerge.

For healthcare providers:

• Counsel families about the potential for attention difficulties as part of long-term follow-up care.
• Consider screening for attention problems in school-aged children who have undergone esophageal atresia repair.
• When deciding between surgical approaches, weigh the potential cognitive risks of minimally invasive surgery against its other benefits.

Limitations and future research

This study provides valuable insights, but it’s important to recognize its limitations:

• The sample size was relatively small (65 children).
• The surgeries were performed 8-17 years ago, and techniques have likely improved.
• The study can show associations but cannot prove that the surgical approach directly causes attention problems.

Future research directions include:

• Larger studies to confirm these findings
• Investigation of the specific mechanisms by which surgery might affect brain development
• Evaluation of newer surgical and anesthesia techniques to see if they have similar cognitive effects
• Development of strategies to minimize cognitive risks during early-life surgeries

Conclusions

• Children born with esophageal atresia generally show normal intelligence and school performance.
• However, they are at risk for attention problems, particularly if they underwent minimally invasive surgery or come from a lower socioeconomic background.
• Long-term follow-up and awareness of potential cognitive challenges are important for optimizing outcomes in these children.
• The findings highlight the need to consider potential cognitive effects when weighing the pros and cons of different surgical approaches for newborns.