Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically fragile toddlers

Current status of intractable pediatric gastroesophageal reflux disease in Japan: a nationwide survey

PURPOSE

A nationwide survey was conducted to investigate the current status of pediatric gastroesophageal reflux disease (GERD) in Japan, with special reference to the characteristics of intractable GERD.

METHODS

Data were collected using a questionnaire from facilities specializing in the treatment of pediatric GERD in Japan. Intractable GERD was defined as follows: I, no symptomatic improvement after 8 weeks of optimal medical treatment (OMT) plus fundoplication; II, no symptomatic improvement after 8 weeks of OMT and with no indications for fundoplication; and III, no symptomatic improvement after surgery without OMT.

RESULTS

We collected data from 3,463 pediatric patients with GERD from 91 institutions, and 81 satisfied the definition of intractable GERD. Additional clinical information was obtained from 56 patients, and 41 represented cases of definite intractable GERD. The main underlying disorders included neurological impairment (NI), esophageal atresia (EA), and congenital heart disease (CHD), which altogether accounted for 85% of patients. Of the 41 patients, 33 received fundoplication, and the remaining 8 received medical treatment alone because surgery was considered unsuitable.

CONCLUSIONS

The nationwide survey revealed that pediatric intractable GERD is rare in Japan. Three main underlying disorders-NI, EA, and CHD-were implicated in the majority of cases of intractable GERD.

Prucalopride for Treatment of Upper Gastrointestinal Symptoms in Children

BACKGROUND

Upper gastrointestinal (GI) symptoms are common in pediatrics, and few prokinetics for children exist. The goal of this study was to determine the efficacy of prucalopride for treatment of upper GI symptoms and feeding difficulties in children.

METHODS

This was a retrospective study of patients prescribed prucalopride for upper GI symptoms at a single tertiary care center from July 2019 to January 2021. Demographic data, the indication for prucalopride, comorbidities, and feeding data were recorded. The primary outcome was improvement in the primary upper GI symptom at first follow-up after prucalopride initiation. Univariable and multivariable analyses were used to assess for factors associated with improvement.

RESULTS

The final study population included 71 patients who received prucalopride for treatment of upper GI symptoms. The most common indications were nausea (44%), feeding difficulties (20%), and reflux (11%). Patients had a median age of 16.7 years (range 1.9-21.8 years), and they had received 4 ± 4.8 years of care in our GI clinic and trialed 3.0 ± 2.0 other GI medications by the time of the prucalopride prescription. At follow-up 3.6 ± 2.9 months after the prucalopride was prescribed, 46 patients (65%) had symptomatic improvement of the upper GI symptom. Improvement was more likely in patients with enteral tubes (p = 0.04), pulmonary comorbidities (p = 0.006), and neurologic comorbidities (p = 0.02). Amongst patients with feeding difficulties, 79% of patients showed improvements in oral or tube feeding.

CONCLUSIONS

In this sample of children treated for refractory upper GI symptoms at a single tertiary care center, patients showed improvements in symptoms like nausea, reflux, and feeding difficulties after starting prucalopride.

Complications in patients with neurological impairment after gastrostomy

BACKGROUND

Neurological impairment (NI) is responsible for most conditions that require a permanent gastrostomy tube. The present study assessed the occurrence of short- and long-term complications after video-assisted gastrostomy (VAG) in patients with NI.

METHODS

The incidence of short- (<6 months) and long-term (over 2 years) complications of VAG were analyzed in a retrospective study. The differences between the incidence of the complications of VAG according to the age at surgery (≤15 years vs. ≥16 years) were also evaluated. The short- and long-term complications observed were granulation tissue formation, infection requiring antibiotic treatment, skin problems, perigastrostomy leakage, vomiting, accidental tube dislodgement, dumping syndrome, ileus, and peritonitis.

RESULTS

Eighty-two patients were evaluated for short- and long-term complications. The long-term complication rate was significantly lower than the short-term complication rate (P = 0.0026). Onodera's prognostic nutritional index before VAG in patients with long-term complications was significantly lower than in patients without such complications (P = 0.046). The incidence of long-term granulation tissue formation, infection, and vomiting were significantly lower than those of similar short-term complications. Long-term skin problems were associated with short-term skin problems (odds ratio: 18.95; 95% confidence interval: 4.53-92.98; P < 0.001). The number of patients ≥16 years old with short- and long-term skin problems was significantly higher than in patients ≤15 years old (P = 0.0014 and P = 0.0073, respectively).

CONCLUSIONS

The incidence rate of granulation tissue formation and infection after VAG were lower in the long term than in the short term. However, patients ≥16 years old presented with persistent complications.

Multidisciplinary approach to assessment and intervention of feeding problems in children with autism spectrum disorders: a clinical perspective

Purpose

The aim of this paper is to share the details of a multidisciplinary approach, which includes occupational therapy, and to review the factors that should be considered in the evaluation and treatment of children with autism spectrum disorders (ASD) who are excessively selective in their food choices. Issues in this area are complex and often related to several complementary domains (medical, nutritional, psychosocial, sensorimotor, etc.). However, feeding disorders are frequently assessed and treated from a single discipline and important issues are missed or confounded.

Design/methodology/approach

A team of experienced clinicians in the field of paediatric feeding disorders gathered the knowledge and experience they acquired from working with individuals with ASD as well as with individuals with other neurodevelopmental diagnosis. A review of current literature in paediatric feeding disorders was used to document and explicate the multifactorial nature of feeding disorders in children with ASD and justify the need for a multidisciplinary approach to issues in this area.

Findings

Feeding disorders in children with ASD are linked to multiple sensory, motor, behavioural, nutritional and gastrointestinal comorbidities. A multidisciplinary approach is needed and increasingly recommended. However, multidisciplinary teams, specialised in the care of children with ASD and feeding issues, continue to be difficult to locate and access for families. The authors sought to highlight the signs of feeding problems in children with ASD from different domains and share a model of a multidisciplinary approach that can lead to more successful interventions.

Originality/value

The detailed description of the domains linked to feeding issues and the clinical descriptions provided throughout the paper create a roadmap for other clinicians aiming to set up similar teams.

Mealtime Environment and Control of Food Intake in Healthy Children and in Children with Gastrointestinal Diseases

Parental feeding practices and mealtime routine significantly influence a child’s eating behavior. The aim of this study was to investigate the mealtime environment in healthy children and children with gastrointestinal diseases. We conducted a cross-sectional case–control study among 787 healthy, typically developing children and 141 children with gastrointestinal diseases, aged two to seven years. Parents were asked to provide data on demographics and describe their mealtime environment by answering to 24 closed-ended questions. It was found that the majority of the children had the same number of meals every day and at the same hour. Parents of both groups exerted considerable control on the child’s food intake by deciding both when and what their child eats. Almost one third of the parents also decided how much their child eats. The two groups differed significantly in nine of the 24 questions. The study showed that both groups provided structured and consistent mealtime environments. However, a significant proportion of children did not control how much they eat which might impede their ability to self-regulate eating. The presence of a gastrointestinal disease was found to be associated with reduced child autonomy, hampered hunger cues and frequent use of distractions during meals.

Botulinum Toxin as a Treatment for Feeding Difficulties in Young Children

OBJECTIVE

To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children.

STUDY DESIGN

A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ² or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement.

RESULTS

A total of 85 patients who received 118 injections were included in the final analysis; 57 patients (67%) had partial or complete improvement in symptoms after IPBI. Among the 55 patients with enteral tubes, there was an improvement in feeding, with more patients receiving at least some oral feeds after IPBI compared with before (26/55 vs 15/55; P = .004) and fewer patients receiving postpyloric feeds after IPBI compared with before (12/55 vs 21/55; P = .01). Twenty-six patients (31%) received repeat IPBI within 1 year, with only 6 patients receiving IPBI more than twice.

CONCLUSIONS

IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.

Postfundoplication retching: Strategies for management

BACKGROUND

Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right.

METHODS

A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered.

CONCLUSIONS

Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided.

LEVEL OF EVIDENCE

II-V.

Association between Adherence to the Antioxidant-Rich Mediterranean Diet and Sensory Processing Profile in School-Aged Children: The Spanish Cross-Sectional InProS Project

We assessed the association between adherence to the Mediterranean diet (MD) and sensory processing in 583 Spanish children aged 3–7 years from the InProS project in Alicante, Spain. Child sensory processing was measured using the short sensory profile (SSP); atypical sensory performance was defined as SSP total score <155; tactile sensitivity <30; taste/smell sensitivity <15; movement sensitivity <13; under-responsive/seeks sensation <27; auditory filtering <23; low energy/weak <26; and visual/auditory sensitivity <19 scores. Adherence to the MD was measured using the Mediterranean diet quality index KIDMED. Multiple Poisson regression models with robust variance, based on the Huber sandwich estimate, were used to obtain prevalence ratios (PR). Our findings suggested that a lower prevalence of atypical tactile and taste/smell sensitivity were associated with having medium (PR = 0.50, 95% CI: 0.25; 0.99; PR = 0.57, 95% CI: 0.33; 0.99, respectively) and high adherence to the MD (PR = 0.58, 95% CI: 0.34; 0.99; PR = 0.33, 95% CI: 0.19; 0.60, respectively), and of atypical low energy/weak with having medium adherence to the MD (PR = 0.37, 95% CI: 0.16; 0.83). A two-point increase in adherence to the MD showed a general positive effect against atypical sensory performance, although it was statistically significant on taste/smell sensitivity (PR = 0.71, 95% CI: 0.59; 0.85) and low energy/weak (PR = 0.80, 95% CI: 0.64; 0.99) subscales. To our knowledge, this is the first study that shows a protective effect of adherence to the MD against prevalence of atypical sensory processing in school-aged children. Further research from longitudinal studies is required to confirm these findings.

Feeding difficulties in children with non-IgE-mediated food allergic gastrointestinal disorders

OBJECTIVE

To review the signs and symptoms of feeding difficulties in children with non-IgE-mediated food allergic gastrointestinal disorders and provide practical advice, with the goal of guiding the practitioner to timely referral for further evaluation and therapy. Various management approaches are also discussed.

DATA SOURCES

Articles and chapters related to normal feeding patterns and the diagnosis and management of feeding difficulties in children were reviewed.

STUDY SELECTIONS

Selections were based on relevance to the topic and inclusion of diagnostic and management recommendations.

RESULTS

Because most non-IgE-mediated food allergic gastrointestinal disorders occur in early childhood, feeding skills can be disrupted. Feeding difficulties can result in nutritional deficiencies, faltering growth, and a significant impact on quality of life. Specific symptoms related to each non-IgE-mediated food allergic gastrointestinal disorder can lead to distinctive presentations, which should be differentiated from simple picky eating. Successful management of feeding difficulties requires that the health care team views the problem as a relational disorder between the child and the caregiver and views its association with the symptoms experienced as a result of the non-IgE-mediated food allergic gastrointestinal disorder. Addressing the child's concern with eating needs to be done in the context of the family unit, with coaching provided to the caregiver as necessary while ensuring nutritional adequacy. Treatment approaches, including division of responsibility, food chaining, and sequential oral sensory, are commonly described in the context of feeding difficulties.

CONCLUSION

A multidisciplinary approach to management of feeding difficulties in non-IgE-mediated food allergic gastrointestinal disorders is of paramount importance to ensure success.

Children with diseases of the upper gastrointestinal tract are more likely to develop feeding problems

Feeding problems may give rise to a number of adverse effects with organic, psychological, developmental and social impact. Specific medical conditions, especially diseases of the gastrointestinal system, are known to be associated with feeding problems. We searched databases, including MEDLINE and the Cochrane Library, for papers published in English from 1990 to March 2018. Keywords included "gastrointestinal diseases", "gastroesophageal reflux disease", "eosinophilic esophagitis", "food allergy", "children", "infants", and "feeding problems". We concluded that children with diseases of the upper gastrointestinal tract, especially those with gastroesophageal reflux disease and eosinophilic esophagitis, are more likely to develop feeding problems. However, further epidemiological studies are needed to determine the prevalence and the specific characteristics of feeding problems in children with certain upper gastrointestinal diseases, as well as the exact causal relationship between them.

Gabapentin Improves Oral Feeding in Neurologically Intact Infants With Abdominal Disorders

Feeding intolerance, poor oral feeding skills, and retching are common symptoms seen in medically complex infants with a history of abdominal disorders and surgical interventions, such as gastrostomy tube placement and Nissen fundoplication. Visceral hyperalgesia may play a role in the underlying pathophysiology. We report the use of orally administered gabapentin in 3 infants with presumed visceral hyperalgesia presenting as poor tolerance of enteral and oral feeds. Retching and outward discomfort associated with feeds was resolved within 2 to 3 days of initiation of therapy. Full oral feeds were obtained in all 3 patients within 3 to 4 months of starting gabapentin without changing adjunctive medications or therapies. After attainment of full oral feeds, all patients were successfully weaned off gabapentin over a month, with no notable side effects, signs of withdrawal, or impact on ability to feed by mouth.

An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children

BACKGROUND

Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function.

PURPOSE

This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).

Intervention for Feeding Difficulties in Children With a Complex Medical History: A Randomized Clinical Trial

OBJECTIVE

This study aimed to compare outcomes of different multidisciplinary feeding therapy approaches in children with feeding difficulties.

METHODS

Children aged 2 to 6 years with feeding difficulties and a medically complex history (MC) were recruited. Children with feeding difficulties and a nonmedically complex history (NMC) were included as a comparison group. Participants attended a clinical assessment, and eligible participants were randomized to receive targeted feeding intervention incorporating either operant conditioning or systematic desensitization. Parents could elect to receive intervention in an intensive (10 sessions in a week) or weekly (10 sessions during 10 weeks) format. Both groups received immersive parent training. A review was completed 3 months post-intervention.

RESULTS

In total, 98 participants were eligible to participate (MC, n = 43; NMC, n = 55). Data from 20 children from the MC group (47%) and 41 children from the NMC group (75%) were included in the final analysis. Clinically significant improvements were observed following both arms of therapy, consistent with previous research. Parents of children in the MC arm were significantly more likely to elect for intensive intervention than weekly (MC = 12/20, 60%; 12/41, 29%; P = 0.02).

CONCLUSIONS

Both therapy protocols were considered clinically effective. The difference in attrition rates between the etiological groups suggests primary differences in how service delivery should be managed. Progress for the medically complex child may be slower while medical issues are stabilized, or while the focus for parents shifts to other developmental areas. In planning services for a medically complex group, therefore, it is essential that consideration be given to medical and family needs.

Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention

Children with severe impairment of the central nervous system (CNS) experience gastrointestinal (GI) symptoms at a high rate and severity, including retching, vomiting, GI tract pain, and feeding intolerance. Commonly recognized sources of symptoms include constipation and gastroesophageal reflux disease. There is growing awareness of sources due to the impaired nervous system, including visceral hyperalgesia due to sensitization of sensory neurons in the enteric nervous system and central neuropathic pain due to alterations in the thalamus. Challenging the management of these symptoms is the lack of tests to confirm alterations in the nervous system as a cause of symptom generation, requiring empirical trials directed at such sources. It is also common to have multiple reasons for the observed symptoms, further challenging management. Recurrent emesis and GI tract pain can often be improved, though in some not completely eliminated. In some, this can progress to intractable feeding intolerance. This comprehensive review provides an evidence-based approach to care, a framework for recurrent symptoms, and language strategies when symptoms remain intractable to available interventions. This summary is intended to balance optimal management with a sensitive palliative care approach to persistent GI symptoms in children with severe impairment of the CNS.

Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients

Background/Aims

The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and ¹³C-acetate breath test (¹³C-ABT) analyses.

Methods

¹³C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the ¹³C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t_1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t_1/2.

Results

The mean t_1/2 of all patients was 215.5 ± 237.2 minutes and the t_1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t_1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t_1/2 ≥ 140 minutes.

Conclusion

The present study demonstrated that GE with t_1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.

A baseline impedance analysis in neurologically impaired children: A potent parameter for estimating the condition of the esophageal mucosa

BACKGROUND

The aim of the present study was to investigate whether the baseline impedance (BI) value is a useful parameter to evaluate the condition of the esophageal mucosa in neurologically impaired (NI) children undergoing multichannel intraluminal impedance pH measurements (pH/MII).

METHODS

The retrospective study included 55 NI patients ≤15 years. The patients were divided into acid gastroesophageal reflux disease (GERD), non-acid GERD and GERD (-) groups. Furthermore, the patients in the acid GERD group were subdivided into erosive reflux disease (ERD) and non-erosive reflux disease (NERD) groups. pH/MII parameters and BI values (Z1-6) were compared among three groups or between two groups, respectively. A Spearman's correlation analysis was used for the correlation analysis of pH/MII parameters and BI values. A receiver operator characteristic curve analysis was used to evaluate the optimum cut-off values of BI to discriminate ERD patients.

KEY RESULTS

The BI values of the proximal and the distal channels in ERD group were significantly lower than those in NERD group. The BI values of the distal channels demonstrated significant negative correlations with acid exposure related pH/MII parameters. The optimal cut off value of BI in the most distal channel was determined to be 1500 Ω.

CONCLUSIONS & INFERENCES

The present study suggested that NI children with reflux esophagitis were likely to suffer mucosal damage up to the proximal esophagus and cut-off BI values may help estimate the presence of reflux esophagitis. Baseline impedance is a potent parameter, reflecting the esophageal mucosal damage in NI children who have difficulty in undergoing endoscopic examinations.

Food allergy and the gut

Food allergy develops as a consequence of a failure in oral tolerance, which is a default immune response by the gut-associated lymphoid tissues to ingested antigens that is modified by the gut microbiota. Food allergy is classified on the basis of the involvement of IgE antibodies in allergic pathophysiology, either as classic IgE, mixed pathophysiology or non-IgE-mediated food allergy. Gastrointestinal manifestations of food allergy include emesis, nausea, diarrhoea, abdominal pain, dysphagia, food impaction, protein-losing enteropathy and failure to thrive. Childhood food allergy has a generally favourable prognosis, whereas natural history in adults is not as well known. Elimination of the offending foods from the diet is the current standard of care; however, future therapies focus on gradual reintroduction of foods via oral, sublingual or epicutaneous food immunotherapy. Vaccines, modified hypoallergenic foods and modification of the gut microbiota represent additional approaches to treatment of food allergy.

Non-IgE-mediated gastrointestinal food allergies in children

Non-IgE-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) including food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), and food protein-induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under-diagnosed. Non-IgE-GI-FA have a favorable prognosis, with majority resolving by age 3-5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.

Brain Lesions among Orally Fed and Gastrostomy-Fed Dysphagic Preterm Infants: Can Routine Qualitative or Volumetric Quantitative Magnetic Resonance Imaging Predict Feeding Outcomes?

INTRODUCTION

The usefulness of qualitative or quantitative volumetric magnetic resonance imaging (MRI) in early detection of brain structural changes and prediction of adverse outcomes in neonatal illnesses warrants further investigation. Our aim was to correlate certain brain injuries and the brain volume of feeding-related cortical and subcortical regions with feeding method at discharge among preterm dysphagic infants.

MATERIALS AND METHODS

Using a retrospective observational study design, we examined MRI data among 43 (22 male; born at 31.5 ± 0.8 week gestation) infants who went home on oral feeding or gastrostomy feeding (G-tube). MRI scans were segmented, and volumes of brainstem, cerebellum, cerebrum, basal ganglia, thalamus, and vermis were quantified, and correlations were made with discharge feeding outcomes. Chi-squared tests were used to evaluate MRI findings vs. feeding outcomes. ANCOVA was performed on the regression model to measure the association of maturity and brain volume between groups.

RESULTS

Out of 43 infants, 44% were oral-fed and 56% were G-tube fed at hospital discharge (but not at time of the study). There was no relationship between qualitative brain lesions and feeding outcomes. Volumetric analysis revealed that cerebellum was greater (p < 0.05) in G-tube fed infants, whereas cerebrum volume was greater (p < 0.05) in oral-fed infants. Other brain regions did not show volumetric differences between groups.

CONCLUSION

This study concludes that neither qualitative nor quantitative volumetric MRI findings correlate with feeding outcomes. Understanding the complexity of swallowing and feeding difficulties in infants warrants a comprehensive and in-depth functional neurological assessment.

Feeding problems in infancy and early childhood: evolutionary concept analysis

AIM

The aim of this study was to report an analysis of the concept of pediatric feeding problems.

BACKGROUND

Reviews of the literature on pediatric feeding problems and disorders repeatedly reference the lack of a shared conceptualization of feeding problems. It is difficult to track aetiology, prevalence and incidence of a phenomenon when available definitions and diagnoses lack practical utility.

DESIGN

An evolutionary concept analysis.

DATA SOURCES

A search was conducted in October 2014 of Google Scholar, CINAHL, PubMed and Web of Science databases, with MeSH terms and key words including: failure to thrive, feeding disorder/difficulty/problems, infantile anorexia, oral aversion, mealtime behaviour and dysphagia. Inclusion criteria were: subject of feeding problems, index children 0-10 years of age, English language and full text.

METHODS

The articles (n = 266) were sorted into disciplines of authorship, including Psychology, Medicine, Nursing, Nutrition, Occupational Therapy, Speech Language Pathology or Other. The sample was divided into a historical sample (n = 42) for pre-2000 articles and current for those published post-2000. The current sample was later reduced to 100 and coded for surrogate terms, related concepts, attributes, antecedents and consequences.

RESULTS

The historical view of pediatric feeding problems shows a tradition of mother blame or parental culpability, both direct and indirect. Currently, there exist many different definitions and typologies, but none have sound validity or generalizability. Areas of attribute consensus across disciplines are problematic feeding behaviours and selective or restrictive intake.

CONCLUSION

A spectrum conceptualization of feeding problems is suggested for further development, with attributes that would be critical to have a feeding problem.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline

OBJECTIVE

To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding.

STUDY DESIGN

Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components.

RESULTS

All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost.

CONCLUSIONS

Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01206478.

How to Improve Eating Behaviour during Early Childhood

Eating behaviour disorder during early childhood is a common pediatric problem. Many terminologies have been used interchangeably to describe this condition, hindering implementation of therapy and confusing a common problem. The definition suggests an eating behaviour which has consequences for family harmony and growth. The recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not cover the entire spectrum seen by pediatricians. Publications are substantive but level of evidence is most of the time low. This purpose of this review is to clarify terminology of eating behaviour problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counselling and, where necessary, behavioural therapy is clarified. It is hoped that the condition will make its way into mainstream pediatrics to allow these children, and their families, to receive the help they deserve.

Gabapentin for management of recurrent pain in 22 nonverbal children with severe neurological impairment: a retrospective analysis

BACKGROUND

Children with severe impairment of the central nervous system (CNS) have a high incidence of distressing symptoms, with many experiencing frequent recurrent pain episodes.

OBJECTIVE

The study objective was to describe presenting pain behaviors, daily dose, and response to gabapentin for the management of frequent recurrent pain in this population.

METHODS

A retrospective analysis was performed with data from 22 children with severe impairment of the CNS residing at a long-term care facility, treated with gabapentin for recurrent pain behaviors. Response was considered significant if the frequency and severity of symptoms decreased by more than 50% as assessed by nursing staff.

RESULTS

Pain behaviors commonly reported included facial grimacing, crying, or moaning. Intermittent increase in muscle tone was identified in 86% (n=19). Gastrointestinal (GI) symptoms occurred in 64% (n=14), including pain localized to the GI tract and vomiting. All were assessed for nociceptive pain sources, many with repeated testing. Most were on medications for spasticity (n=20, 91%) and gastroesophageal reflux disease (GERD) (n=22, 100%) prior to gabapentin use. Of the 22 treated with gabapentin, 21 (91%) had a significant decrease in symptoms. No serious adverse events occurred. The mean gabapentin dose for children five years of age or less (n=11) was 50 mg/kg/day (95% CI 45-56) compared to children older than 11 years (n=11) with a mean dose of 36 mg/kg/day (95% CI 34-38).

CONCLUSIONS

Gabapentin appears to be an effective treatment for children with severe impairment of the CNS and recurrent pain behaviors, including intermittent changes in muscle tone. Dosing information can guide treatment trials and future prospective studies.

A practical approach to classifying and managing feeding difficulties

Many young children are thought by their parents to eat poorly. Although the majority of these children are mildly affected, a small percentage have a serious feeding disorder. Nevertheless, even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences. Therefore, pediatricians must take all parental concerns seriously and offer appropriate guidance. This requires a workable classification of feeding problems and a systematic approach. The classification and approach we describe incorporate more recent considerations by specialists, both medical and psychological. In our model, children are categorized under the 3 principal eating behaviors that concern parents: limited appetite, selective intake, and fear of feeding. Each category includes a range from normal (misperceived) to severe (behavioral and organic). The feeding styles of caregivers (responsive, controlling, indulgent, and neglectful) are also incorporated. The objective is to allow the physician to efficiently sort out the wide variety of conditions, categorize them for therapy, and where necessary refer to specialists in the field.

Feeding difficulties in children with food protein-induced gastrointestinal allergies

BACKGROUND AND AIM

There is paucity of data on the prevalence of feeding difficulties in Food Protein-Induced Gastrointestinal Allergies (FPIGA) and their clinical characteristics. However, it is a commonly reported problem by clinicians. We set out to establish the occurrence of feeding difficulties in children with FPIGA, the association with gastrointestinal and extra-intestinal symptoms and number of foods eliminated from the diet.

METHODS

This retrospective observational analysis was performed in patients seen between 2002 and 2009 at Great Ormond Street Children's Hospital, Gastroenterology Department, London. Medical records where FPIGA was documented using the terms from the National Institute of Allergy and Infectious Disease and National Institute of Clinical Excellence and confirmed using an elimination diet, followed by a challenge were included. Feeding difficulties were assessed using a criteria previously used in healthy toddlers in the UK.

RESULTS

Data from 437 children (203 female) were collected. Significantly more children with feeding difficulties presented with abdominal distention and bloating (P = 0.002), vomiting (P < 0.0001), weight loss (P < 0.0001), rectal bleeding (P = 0.025), and constipation (P < 0.0001). We also found that having extra-intestinal manifestations were significantly (P < 0.0001) associated with the presence of feeding difficulties. Additionally, a significantly higher number of foods eliminated from the diet in the children with/without feeding difficulties (P = 0.028).

CONCLUSIONS

Clinical manifestations like vomiting, constipation, rectal bleeding, weight loss, and the presence of extra-intestinal manifestations in addition to the number of foods avoided are in our FPIGA population linked to feeding difficulties.

Psychotropic medications for pediatric functional gastrointestinal disorders

We describe the use of psychotropic medications in the treatment of functional gastrointestinal disorders (FGIDs) in children based on available data. We address their safety and efficacy. Most pediatric gastroenterologists do not or are not able to collaborate with child psychiatrists, so it may be beneficial for pediatric gastroenterologists to have a working knowledge of off-label psychotropic drugs to improve functional symptoms. We recommend that efforts be made to involve both the children and their families from the beginning, adverse effects be mentioned, and the treatment plan be explained.

Posttraumatic feeding disorder in low birth weight young children: a nested case-control study of a home-based intervention program

Low birth weight infants (LBW) are reported to be at risk for posttraumatic feeding disorder (PTFD). In this study, we evaluated the outcome of an intervention program for infants with PTFD. LBW infants with PTFD (N=21) completed feeding behavior questionnaires at entry and after completing the program and were compared to a matched control group. PTFD group infants showed a significantly high rate of food disorder symptoms at entry but not at follow-up compared to the control group. The intervention program for PTFD infants resulted in reduced feeding disorder symptoms.

Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH–multichannel intraluminal impedance measurements

BACKGROUND

Gastroesophageal reflux disease (GERD) in patients with neurological impairment (NI) has not been fully studied before and after fundoplication procedure because their characteristics such as generalized gastrointestinal dysmotility, non-acid reflux, and the proximal reflux due to feeding of enteral nutrition via a nasogastric tube prevent their GERD from being detected by 24 h pH monitoring. The aim of this study was to elucidate whether multichannel impedance-pH measurement (pH/MII) is able to detect the subtypes of GERD and the differences in the reflux episodes of the severity of GERD, the ingestion pathway, and before and after fundoplication. The second aim was to determine whether a trial evaluation of dry swallows was able to be used to assess the esophageal motility of NI patients as an alternative examination.

PATIENTS AND METHODS

The 24 h pH/MII was conducted on 20 NI children [15 were the patients before Nissen's fundoplication (BN), of whom, six were fed orally (FO) and nine were fed via nasogastric tube (NGT), and five were the patients after Nissen's fundoplication (AN)]. All reflux episodes were evaluated and compared between patients with pathological GERD (PG) and non-pathological GERD (NG) and between patients who had FO and NGT and patients between BN and AN. Dry swallows were conducted to evaluate the esophageal motility. The average bolus presence time (BPT) and total bolus transit time (TBTT) were compared between the PG and NG, FO and NGT, and the BN and AN subgroups.

RESULTS

A total of 1,064 reflux episodes were detected by pH/MII. Of those, 303 (28.5 %) were non-acid-related and 477 episodes reached the proximal esophagus. Of the 12 patients (57.1 %) showing pathological GERD, two cases (16.7 %) demonstrated predominantly weakly acidic PG. More than half of the reflux episodes of PG patients reached to the proximal esophagus. The numbers of total reflux and proximal reflux episodes in the PG were significantly higher than those in NG patients. The number of proximal reflux episodes in the FO group was significantly higher than that in the NGT groups, whereas NGT patients showed more non-acidic reflux episodes than FO patients. A trial evaluation of dry swallows demonstrated no significant differences in this study.

CONCLUSION

The pH/MII was useful to detect the subtype of GERD in NI patients which could not be detected by 24 h pH monitoring. It can, therefore, be considered to have first priority for testing NI patients who are suspected to be suffering from GERD.

Diffuse esophageal spasm in children referred for manometry

Diffuse esophageal spasm (DES) causes chest pain and/or dysphagia in adults. We reviewed charts of 278 subjects 0 to 18 years of age after esophageal manometry to describe the frequency and characteristics of DES in children. Patient diagnoses included normal motility (61%), nonspecific esophageal motility disorder (20%), DES (13%, n=36), and achalasia (4%). Of patients with DES, the most common chief complaint was food refusal in subjects younger than 5 years (14/24, 58%) and chest pain in subjects older than 5 years (4/12, 33%). Comorbid medical conditions, often multiple, existed in 33 subjects. DES should be considered when young children present with food refusal.

Sensory processing issues in young children presenting to an outpatient feeding clinic

OBJECTIVES

The aim of the study was to describe the relation between sensory issues and medical complexity in a series of patients presenting to an outpatient multidisciplinary feeding team for evaluation, by a standardized measure of sensory-processing abilities.

METHODS

A retrospective chart review of all of the patients seen from 2004 to 2009 on 2 key variables: medical diagnostic category and short sensory profile (SSP) score.

RESULTS

On the SSP, 67.6% of children scored in the clinical ("definite difference") range. The most common diagnostic categories were developmental (n = 23), gastrointestinal (n = 16), and neurological (n = 13). Behavioral and cardiorespiratory medical diagnostic categories were significantly related to SSP total score and SSP definite difference score.

CONCLUSIONS

Children who present for feeding evaluation do indeed tend to have clinically elevated scores regarding sensory processing, and these elevated scores are significantly related to certain medical diagnostic categories. Future research is needed to determine why these significant relations exist as well as their implications for treatment of feeding-related issues.

Practical dietary management of protein energy malnutrition in young children with cow's milk protein allergy

Cow's milk protein allergy (CMPA) affects between 1.9 and 4.9% of infants and young children. This food allergy requires the complete elimination of cow's milk and its derivatives, impacting on nutritional status. The risk of having protein energy malnutrition (PEM) in children with CMPA has been well documented. In 2007, the World Health Organisation published guidelines on the dietary management of PEM, which has impacted on the recommendations and composition on specialist feeds for many chronic diseases, but not on CMPA. The main change in management of the child with PEM is the protein energy ratio and energy requirements. The ideal protein energy ratio lies between 8.9 and 11.5%, which would ensure a deposition of about 70% lean and 30% fat mass. In addition, for optimal catch-up growth between 5 and 10 g/kg/day, energy requirements should be between 105 and 126 kcal/kg/day. Although most current hypoallergenic formulas fall well within the recommendation for protein, there is a problem in achieving energy requirements. As a result, modular additions are often made, disturbing the protein energy ratio or feeds are concentrated, which impacts on osmolality. We therefore aimed to review current guidelines on PEM and how these can be applied in the management of the malnourished child with CMPA.

Screening criteria for diagnosis of infantile feeding disorders as a cause of poor feeding or food refusal

OBJECTIVES

Infantile feeding disorders (IFDs) are a common cause of food refusal, failure to thrive, and vomiting, but they may be difficult to diagnose. We have previously identified certain patterns of pathological feeding and behaviors as high-risk characteristics for IFDs and subsequently developed the diagnostic Wolfson criteria. Here, we evaluate these high-risk behaviors and prospectively compare the Wolfson criteria with 2 existing classifications of IFD, the Chatoor and that in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

PATIENTS AND METHODS

Infants and young children referred for food refusal were invited to participate by completing a feeding pattern questionnaire. Following physicians' interview and examination, patients were scored by all 3 criteria and enrolled in a structured treatment program for IFD. Infants whose food refusal was associated with an organic cause served as a comparison group. The ability of the criteria to detect IFD and to predict response to therapy was compared with an intention-to-treat analysis.

RESULTS

Eighty-five infants with new-onset IFD and 55 controls were included. The Wolfson criteria, Chatoor, and DSM-IV accurately diagnosed 100%, 77%, and 56% of the patients with IFD, respectively. Anticipatory gagging occurred in 47% of the children with IFD compared to 2% controls (P < 0.001). The response to therapy was similar among the 3 criteria (73-76%), suggesting that the Wolfson criteria did not incorrectly diagnose organic disease as IFD. The 20 infants who were diagnosed as having IFD by Wolfson but not by Chatoor responded equally well (80%) to an IFD treatment program.

CONCLUSIONS

Diagnostic criteria of IFD that are based on food refusal, pathological feeding, and anticipatory gagging have a higher detection rate than the present criteria and are simpler to implement.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).

Empirically supported treatments for feeding difficulties in young children

Pediatric feeding problems are common among children and present severe issues for families. Unfortunately, treatment outcome studies with this population are sparse. The current study reviews the literature regarding treatment studies of children with severe feeding issues, provides an overview of empirically supported treatments for children who do eat orally, and finally summarizes interventions that attempt to reintroduce oral feeding to children who have been fed by gastrostomy tube or other non-oral feeding route.

Moving from tube to oral feeding in medically fragile nonverbal toddlers

The current article describes a 14-week outpatient protocol for transitioning from gastrostomy tube to oral feeding in toddlers with medical complications. The team ensured that eating skills were mastered before treating patients for 8 weeks with continuous gastrojejunal drip tube feedings and low-dose tricyclic antidepressant and/or gabapentin. We prescribed 6 weeks of megestrol for hunger provocation while withdrawing tube feedings. A chart review after treatment demonstrated 9 subjects were eating exclusively orally and 1 was eating 50% orally.

The Case of the Wretched Retcher

Fundoplication is an effective treatment for severe gastroesophageal reflux disease (GERD) because it provides a mechanical solution to what is essentially a mechanical, not a medical, problem. However, manifestations of feeding intolerance postfundoplasty are well known and include dysphagia, gastric dysfunction, retching, gagging, intestinal dysfunction, and gas bloat syndrome. These difficulties are exacerbated by feeding plans that disregard the mechanical constraints imposed by the operation, particularly limited gastric volume, decreased gastric compliance, diminished ability to burp, sensitivity to osmolarity, and formula composition. These complications are preventable and treatable by informed construction of feeding plans that limit boluses (around 15 mL/kg/bolus), promote proper motility, manage intraluminal air, and limit polypharmacy. This case presentation describes a postfundoplasty infant with severe retching and intolerance treated according to these principles.