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Yang DM, Sabella J, Kroon Van Diest A, Bali N, Vaz K, Yacob D, Di Lorenzo C, Lu PL. Early childhood-onset rumination syndrome is clinically distinct from adolescent-onset rumination syndrome. J Pediatr Gastroenterol Nutr 2024; 78:565-572. [PMID: 38504395 DOI: 10.1002/jpn3.12116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Rumination syndrome (RS) beginning in early childhood or infancy is understudied and challenging to treat. Our objective is to compare the characteristics and outcomes of early-onset (EO) and adolescent-onset (AO) patients with RS. METHODS We conducted an ambidirectional cohort study of children diagnosed with RS at our institution. Patients were included in two groups: EO (RS symptom onset ≤5 years and diagnosis ≤12 years) and AO (onset >12 years). Patient characteristics, severity, and outcomes were compared between the groups. RESULTS We included 49 EO and 52 AO RS patients. The median ages of symptom onset and diagnosis in EO were 3.5 and 6 years, respectively; AO, 14.5 and 15 years. EO RS had a slight male predominance while AO was predominantly female (p = 0.016). EO patients were more likely to have developmental delay (24% vs. 8%, p = 0.029) and less likely to have depression (0% vs. 23%, p < 0.001) or anxiety (14% vs. 40%, p = 0.004). At baseline, EO RS was less severe than AO RS: EO RS had greater regurgitation frequency (p < 0.001) but lower vomiting frequency (p = 0.001), resulting in less meal skipping (p < 0.001), reliance on tube feeding or parenteral nutrition (p < 0.001), and weight loss (p = 0.035). EO RS symptoms improved over time: at follow-up, patients had lower regurgitation (p < 0.001) and vomiting frequency (p < 0.001) compared to baseline. CONCLUSION EO RS is clinically distinct from AO RS, with differences in sex distribution, comorbid conditions, and severity of initial presentation. The pathogenesis and natural history of EO RS may be distinct from that of AO RS.
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Affiliation(s)
- Dennis M Yang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Julia Sabella
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ashley Kroon Van Diest
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Neetu Bali
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karla Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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Lee M, Lee S, Sohn JW, Kim KW, Choi HJ. Assessment Methods for Problematic Eating Behaviors in Children and Adolescents With Autism Spectrum Disorder. Soa Chongsonyon Chongsin Uihak 2024; 35:57-65. [PMID: 38204745 PMCID: PMC10774564 DOI: 10.5765/jkacap.230065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 01/12/2024] Open
Abstract
Autism spectrum disorder (ASD) can be associated with eating problems. However, currently, there is a lack of established guidelines for assessing and addressing eating behaviors in individuals with ASD. This gap in research exists due to the challenges associated with using traditional assessment methods, which may lead to discrepancies in responses and unintentional potential biases from caregivers. In this review, we provided a comprehensive overview of various eating behaviors commonly observed in individuals with ASD. These behaviors include 1) food neophobia, 2) selective eating, 3) binge eating, 4) food avoidance, 5) chewing and swallowing problems, 6) pica, 7) rumination, 8) rituals, and 9) problematic behaviors. Furthermore, we provide a perspective of utilizing digital tools: 1) augmentative and alternative communication; 2) ecological momentary assessment; and 3) video analysis, behavioral analysis, and facial expression analysis. This review explores existing assessment methods and suggests novel assessment aiding together.
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Affiliation(s)
- Miji Lee
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Seolha Lee
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Jong-Woo Sohn
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Ki Woo Kim
- Division of Physiology, Departments of Oral Biology and Applied Life Science, BK21 Four, Yonsei University College of Dentistry, Seoul, Korea
| | - Hyung Jin Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Wide River Institute of Immunology, Seoul National University, Hongcheon, Korea
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3
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Sasegbon A, Hasan SS, Disney BR, Vasant DH. Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterol 2022; 13:440-446. [PMID: 36046491 PMCID: PMC9380772 DOI: 10.1136/flgastro-2021-101856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Syed Shariq Hasan
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin R Disney
- Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Dipesh Harshvadan Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Martinez M, Rathod S, Friesen HJ, Rosen JM, Friesen CA, Schurman JV. Rumination Syndrome in Children and Adolescents: A Mini Review. Front Pediatr 2021; 9:709326. [PMID: 34490165 PMCID: PMC8416921 DOI: 10.3389/fped.2021.709326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: Rumination syndrome involves recurrent regurgitation of food and is believed to be underdiagnosed with patients experiencing long delays in diagnosis. It can be associated with significant social consequences, high rates of school absenteeism, and medical complications such as weight loss. The primary aims of the current review are to assess the literature regarding prevalence, pathophysiology, and treatment outcomes with a focus on neurotypical children and adolescents. Results: Population studies in children/adolescents, 5 years of age or older, range from 0 to 5.1%. There are fewer studies in clinical settings, but the prevalence appears to be higher in patients with other gastrointestinal symptoms, particularly chronic vomiting. While physiologic changes that occur during a rumination episode are well-described, the underlying cause is less well-defined. In general, rumination appears to have similarities to other functional gastrointestinal disorders including dysmotility, possibly inflammation, and an interaction with psychologic function. While diaphragmatic breathing is considered the mainstay of treatment, pediatric data demonstrating efficacy is lacking, especially as an isolated treatment. Conclusion: Pediatric rumination syndrome remains greatly understudied, particularly regarding treatment. There is a need to better define prevalence in both the primary care and subspecialty clinical settings, especially in patients presenting with vomiting or apparent gastroesophageal reflux. There is a need to determine whether treatment of co-morbid conditions results in improvement of rumination. Diaphragmatic breathing needs to be studied and compared to other competing responses.
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Affiliation(s)
- Marc Martinez
- Kansas City University of Medicine and Biosciences, Kansas City, MO, United States
| | - Sandeep Rathod
- Kansas City University of Medicine and Biosciences, Kansas City, MO, United States
| | - Hunter J. Friesen
- University of Kansas School of Medicine, Kansas City, MO, United States
| | - John M. Rosen
- Division of Gastroenteology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, United States
| | - Craig A. Friesen
- Division of Gastroenteology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, United States
| | - Jennifer V. Schurman
- Division of Gastroenteology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, United States
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Chahuan J, Rey P, Monrroy H. Rumination syndrome. A review article. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021. [DOI: 10.1016/j.rgmxen.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chahuan J, Rey P, Monrroy H. Rumination syndrome. A review article. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:163-171. [PMID: 33602544 DOI: 10.1016/j.rgmx.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023]
Abstract
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation of ingested food into the mouth. An unperceived postprandial contraction of the abdominal wall could be a key mechanism. In those patients, retrograde flow of the ingested gastric content into the mouth is produced due to a simultaneous combination of elevated intra-abdominal pressure and negative intrathoracic pressure. The estimated prevalence is around 2% in the general adult population. The main clinical characteristics include: a) early postprandial regurgitation, b) the effortlessly regurgitated material is similar to the ingested food, c) the regurgitated material is spit out or swallowed again. The clinical diagnosis of rumination syndrome relies on the clinical criteria. High resolution esophageal manometry, ideally including impedance monitoring, can be an important adjunct for making the clinical diagnosis. Its management is based on instruction as to the nature of the pathology, education in postprandial diaphragmatic breathing, and the assessment of possible psychiatric comorbidity. Baclofen use is reserved for second-line treatment in patients with refractory symptoms.
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Affiliation(s)
- J Chahuan
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Rey
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Laboratorio de Fisiología Digestiva, Red de Salud UC-Christus, Santiago, Chile
| | - H Monrroy
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Laboratorio de Fisiología Digestiva, Red de Salud UC-Christus, Santiago, Chile.
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The Effect of Enrichment Filling and Engagement Time on Regurgitation and Reingestion Behaviour in Three Zoo-Housed Orangutans. JOURNAL OF ZOOLOGICAL AND BOTANICAL GARDENS 2021. [DOI: 10.3390/jzbg2010002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Regurgitation and reingestion (R/R) is a prevalent, abnormal behaviour observed in captive great apes. R/R may be related to animal welfare and while less R/R appears to occur when apes are provided with browse and continuous foraging opportunities, the aetiology of the behaviour (e.g., foraging time or taste characteristics such as sweetness) is not well understood. This study aimed to determine how environmental enrichment may affect R/R in three zoo-housed, adult orangutans. Over eight weeks, nine fillable enrichment items were provided twice to each orangutan–once with a sweet filling and once with a savoury filling. Enrichment engagement time and R/R behaviour were monitored for 1-h after the item was provided. Individual differences were found in R/R occurrence. One individual was more likely to perform R/R when given enrichment with a sweet filling (p < 0.05), and a second was more likely to R/R with savoury filled enrichment (p < 0.05). R/R behaviour from the third orangutan was unaffected by enrichment filling (p > 0.05), however he engaged longer with savoury filled enrichment, compared to sweet (p < 0.05). No relationship was found between engagement time and amount of R/R behaviour, for any of the orangutans (p > 0.05). While these results should not be generalized without a larger study, they do suggest that diet and enrichment qualities may play a role in the performance of R/R, and individual variation should not be overlooked when considering causation.
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Rauber BF, Milani DC, Callegari-Jacques SM, Fornari L, Bonadeo NM, Fornari F. Predictors of dental erosions in patients evaluated with upper digestive endoscopy: a cross-sectional study. Odontology 2020; 108:723-729. [PMID: 32152820 DOI: 10.1007/s10266-020-00505-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022]
Abstract
The most studied medical condition related with dental erosions is gastroesophageal reflux disease (GERD). The aim of this study was to assess other predictors of dental erosions besides GERD in outpatients referred for upper digestive endoscopy. In a cross-sectional study, we prospectively evaluated 235 patients who underwent upper digestive endoscopy. Patients were interviewed and examined by a trained dentist before the endoscopies, addressing dental health as well as clinical information and food intake. Dental erosion was classified using Basic Erosive Wear Examination score. Potential predictors for dental erosions were: gender, age, chronic use of antidepressants and proton pump inhibitors (PPI), diabetes mellitus, body mass index, heartburn and acid regurgitation scores, chocolate intake, reflux esophagitis and hiatal hernia. Overall prevalence of dental erosions was 23.4%. The most parsimonious Poisson regression model for dental erosions considered age, chocolate intake and acid regurgitation as predictors. Dental erosions were associated with acid regurgitation in patients younger than 50 years [adjusted prevalence ratio (PR) = 1.8 (95% CI 1.1-2.9)] and with chocolate intake in patients older than 50 years [PR = 2.1 (95% CI 1.2-3.9]. The surfaces most eroded were palatine/lingual (n = 25) and occlusal (n = 25), followed by vestibular (n = 5). In outpatients evaluated with upper digestive endoscopy, the variables associated with dental erosions were age younger than 50 years, acid regurgitation and chocolate intake. Referral for dental evaluation should be considered for young patients with GERD and frequent acid regurgitation.
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Affiliation(s)
- Bárbara Facco Rauber
- Program in Dentistry, Faculty of Dentistry, University of Passo Fundo, BR 285 Campus I, RS, Passo Fundo, CEP 99052900, Brazil
| | - Daiane Cristina Milani
- Program in Dentistry, Faculty of Dentistry, University of Passo Fundo, BR 285 Campus I, RS, Passo Fundo, CEP 99052900, Brazil
| | | | | | | | - Fernando Fornari
- Program in Dentistry, Faculty of Dentistry, University of Passo Fundo, BR 285 Campus I, RS, Passo Fundo, CEP 99052900, Brazil.
- Endoscopy Department, Endopasso, Passo Fundo, Brazil.
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Abstract
PURPOSE OF REVIEW Rumination syndrome is a gastrointestinal disorder characterized by effortless regurgitation of recently ingested food. The disorder is rare, but likely under-recognized and leads to impaired quality of life among those affected. This review discusses recent studies which examined the pathophysiology, diagnoses and therapy of rumination syndrome. RECENT FINDINGS The pathogenesis of rumination syndrome remains incompletely understood. Therapeutic options, which appear effective, include behavioral therapy with diaphragmatic breathing and pharmacotherapy with baclofen. A randomized trial of behavioral therapy, biofeedback therapy led to a 74% + /- 6% reduction in rumination activity (from 29 + /- 6 before to 7 + /- 2 daily events after intervention) vs. 1% + /- 14% during sham (from 21 + /- 2 before to 21 + /- 4 daily events after intervention) (P = .001). A recent randomized trial of baclofen at a dose of 10 mg three times daily led to symptomatic improvement in 63% of patients with rumination syndrome. SUMMARY This review summarizes a clinical approach to diagnosing and treating rumination syndrome. Behavioral therapy consisting of diaphragmatic breathing, with or without biofeedback, remains the most effective treatment strategy for patients with rumination syndrome.
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Duodenal Pathology in Patients with Rumination Syndrome: Duodenal Eosinophilia and Increased Intraepithelial Lymphocytes. Dig Dis Sci 2019; 64:832-837. [PMID: 30478768 DOI: 10.1007/s10620-018-5387-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 11/17/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rumination syndrome is a functional gastrointestinal disorder characterized by effortless, postprandial regurgitation. Duodenal eosinophilia has been described in patients with functional dyspepsia. Because of the significant symptomatic overlap between functional dyspepsia and rumination syndrome, we hypothesized that histological changes might exist among patients with rumination syndrome. METHODS We included patients with rumination syndrome in whom we had obtained duodenal biopsies and compared these with controls. Digital images of biopsy specimens were analyzed for routine pathology and eosinophil counts by a pathologist blinded to the case-control status. RESULTS The 22 patients with rumination syndrome had a mean age of 39.2 years (range 21-71) and 77% were female. The 10 controls had a mean age of 34.3 (range 27-69) and 80% were female. There was a significant increase in the mean eosinophil count among the patients with rumination syndrome compared to controls, 26 per mm2 (range 16-42) versus 18 per mm2 (range 10-28), p = 0.006. Intraepithelial lymphocyte counts were significantly higher in rumination patients (mean 15/100 enterocytes, range 8-29) versus controls (mean 11/100 enterocytes, range 11-18), p = 0.02. CONCLUSION Patients with rumination syndrome have subtle duodenal pathology with eosinophilia and increased intraepithelial lymphocyte counts compared to controls.
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Halland M, Pandolfino J, Barba E. Diagnosis and Treatment of Rumination Syndrome. Clin Gastroenterol Hepatol 2018; 16:1549-1555. [PMID: 29902642 DOI: 10.1016/j.cgh.2018.05.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023]
Abstract
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. The disorder appears uncommon, although only limited epidemiologic data are available. Awareness of the characteristic symptoms is essential for recognizing the disorder, and thus avoiding the long delay in diagnosis, that many patients experience. Although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers, a clinical diagnosis can be made in most patients. The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing. This clinical practice update reviews the pathophysiology, diagnosis, and treatment of rumination syndrome. Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting. Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely. Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up. Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome. Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique. Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations. Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients.
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Affiliation(s)
- Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Northwestern Memorial Hospital, Chicago, Illinois.
| | - Elizabeth Barba
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
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Hill SP. ‘Regurgitation and reingestion’ (R/R) in great apes: a review of current knowledge. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/izy.12204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S. P. Hill
- Department of Biological Sciences; University of Chester; Parkgate Road Chester CH1 4BJ United Kingdom
- Department of Veterinary Medicine; University of Cambridge; Madingley Road Cambridge CB3 0ES United Kingdom
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Santucci NR, Hyman PE. Do Functional Gastrointestinal Disorders Affect Growth and Nutrition? J Pediatr 2018; 199:9-10. [PMID: 29731354 DOI: 10.1016/j.jpeds.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Neha R Santucci
- Pediatric Gastroenterology, Hepatology and Nutrition University of Cincinnati Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.
| | - Paul E Hyman
- Pediatric Gastroenterology, Hepatology and Nutrition Louisiana State University Health Sciences Center Children's Hospital of New Orleans New Orleans, Louisiana
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