Assessment of gastric emptying in children: Establishment of control values utilizing a standardized vegetarian meal

Gastrointestinal radionuclide imaging in pediatric age group

Pediatric gastrointestinal imaging plays a crucial role in evaluating and managing digestive system disorders in children. This comprehensive review dives into the nuances of pediatric gastrointestinal imaging techniques, focusing on three specific modalities: gastric emptying scintigraphy (GES), intestinal transit scintigraphy (ITS), and gastrointestinal bleeding scintigraphy. GES involves real-time monitoring of stomach emptying using radiotracers and gamma camera technology. While challenges exist in standardizing protocols due to age-specific meal compositions, GES remains pivotal in diagnosing motility disorders, gastroesophageal reflux, and abdominal pain in children. ITS, utilizing [67Ga], provides insights into gastrointestinal motility disorders such as Hirschsprung disease. It aids in whole-gut transit evaluation, guiding surgical interventions and improving long-term clinical outcomes. Gastrointestinal bleeding scintigraphy, employing [99mTc], assists in diagnosing conditions like Meckel's diverticulum and occult bleeding, offering continuous monitoring to pinpoint the bleeding site along the entire gastrointestinal tract. SPECT-CT improves the accuracy and the standards of care. Each technique's protocol details, clinical indications, and diagnostic capabilities are thoroughly discussed, highlighting the importance of these non-invasive, functional imaging modalities in pediatric gastroenterology.

Transpyloric propagation and liquid gastric emptying in children with foregut dysmotility

BACKGROUND/OBJECTIVES

Gastric emptying (GE) requires precise antropyloroduodenal coordination for effective transpyloric flow, the mechanisms of which are still unclear. We aimed to correlate gastric antral function assessed by antroduodenal manometry (ADM) with GE scintigraphy (GES) for liquid feeds in children with suspected gastrointestinal dysmotility.

METHODS

Children who underwent both ADM and GES over a five-year period were reviewed. ADM tracings were re-analyzed to assess antral frequency, amplitude, and motility index (MI) pre-prandially and postprandially. Transpyloric propagation (TPP) was defined as antegrade propagated antral activity preceding duodenal phase III of the migrating motor complex (MMC). TPP was defined as "poor" if occurring in <50% of all presented duodenal phases III. For GES, regions of interest over the whole stomach, fundus, and antrum were drawn to calculate GE half-time (GE-T_1/2 ) and retention rate (RR) in each region at 1 and 2 h.

RESULTS

Forty-seven children (median age: 7.0 years) were included. Twenty-two had PIPO, 14 functional GI disorders, and 11 gastroparesis. Children with poor TPP had longer GE-T_1/2 (113.0 vs 66.5 min, p = 0.028), higher RR of the whole stomach and fundus at 1 h (79.5% vs 63.5%, p = 0.038; 60.0% vs 41.0%, p = 0.022, respectively) and 2 h (51.0% vs 10.5%, p = 0.005; 36.0% vs 6.5%, p = 0.004, respectively). The pre-prandial antral amplitude of contractions inversely correlated with GE-T_1/2 , RR of the whole stomach, and fundus at 2 h.

CONCLUSIONS

TPP during phase III of the MMC correlated with gastric emptying of liquid and its assessment on ADM might predict abnormalities in postprandial gastric function.

Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines

Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Gastric emptying in healthy children using the Spirulina breath test: The impact of gender, body size, and pubertal development

BACKGROUND

There are no pediatric norms for gastric emptying (GE) measured by nuclear scintigraphy. The ¹³ C-labeled, stable isotope GE breath test (GEBT) is a non-radioactive alternative. We aimed to determine normative GEBT ranges in a cohort of healthy children and examine the influence of age, gender, puberty, and body surface area (BSA).

METHODS

Healthy children ages 8-18 years completed the [¹³ C]-Spirulina platensis GEBT after an overnight fast. Breath samples were collected at baseline, every 15 min × 1 h, then every 30 min for 4 h total. The ¹³ CO₂ excretion rate was determined by the change in ¹³ CO₂ /¹² CO₂ over time in each breath sample, expressed as kPCD (Percent ¹³ C Dose excreted/min). A mixed model with random time was used for multivariable analysis and outcome fit into a quadratic model.

KEY RESULTS

The 100 subjects completed the test meal within allotted time. Median (IQR) age was 13.5 (11.3-15.5) years; 51% were female. Females had lower ¹³ CO₂ excretion rates (slower GE) than males across time (p < 0.001) while decreased excretion rates correlated with higher BSA (p = 0.015). Gender differences were also noted within pubertal stages with females showing slower GE. Multivariable analysis suggested that pre-pubertal children have faster GE than both peri- and post-pubertal groups (p < 0.0001).

CONCLUSIONS & INFERENCES

Gender, puberty, and BSA influence GE rates in healthy children more than age. Although further data are needed, pubertal stage and hormonal influences may be unique factors to consider when assessing GE in children.

13 C-gastric emptying breath tests: Clinical use in adults and children

¹³ C-gastric emptying breath tests (¹³ C-GEBT) are validated, reliable, and non-invasive tools for measurement of gastric emptying (GE) velocity of solids and liquids without radiation exposure or risk of toxicity. They are recommended and routinely used for clinical purposes in adult as well as pediatric patients and can be readily performed onsite or even at the patient's home. However, the underlying methodology is rather complex and test results can be influenced by dietary factors, physical activity, concurrent diseases, and medication. Moreover, epidemiological factors can influence gastric emptying as well as production and exhalation of ¹³ CO₂ , which is the ultimate metabolic product measured for all ¹³ C-breath tests. Accordingly, in this issue of Neurogastroenterology & Motility, Kovacic et al. report performance of the ¹³ C-Spirulina breath test in a large group of healthy children and show significant effects of gender, pubertal status, and body size on test results. The purpose of this mini-review is to evaluate the clinical use of ¹³ C-GEBT in adults and children, exploring available protocols, analytical methods, and essential prerequisites for test performance, as well as the role of GE measurements in the light of the current discussion on relevance of delayed GE for symptom generation.

Functional dyspepsia in children: A study of pathophysiological factors

BACKGROUND AND AIM

Functional dyspepsia (FD) is common in children, and treatment targeted towards the altered pathophysiology can improve outcome. We evaluated FD children for abnormality of gastric accommodation and emptying, psychological stressors (PS), Helicobacter pylori (HP) infection, and post-infectious FD.

METHODS

Diagnosis of FD was based on ROME III criteria. Clinical evaluation including dyspeptic symptom scoring and assessment for PS was performed. Satiety drink test for gastric accommodation, gastroscopy with biopsy for HP infection, and solid meal gastric emptying were performed. Sixty-seven healthy children were enrolled for assessing PS and satiety drink test.

RESULTS

Fifty-five FD children (33 boys, age 12 [6-18] years) with symptoms for 4 (2-48) months and dyspeptic score of 5 (1-13) were enrolled. PS were more common in FD than in controls (46/55 vs 9/67; P < 0.001). Median satiety drink volume was 360 mL (180-1320 mL); no patients had satiety drink volume of < 5th centile of healthy children. The frequency (98% vs 85%; P = 0.01) and severity (65 [10-175] vs 50 [5-130]; P < 0.001) of postprandial symptoms were higher in FD than in controls. Of the postprandial symptoms, pain (20.3% vs 0%; P = 0.000) was present only in FD. Delayed gastric emptying was present in 6.5%, HP infection in 11%, and post-infectious FD in 13% cases. Etiological factor was identified in 87% children, with 20% having multiple factors.

CONCLUSIONS

Abnormality of gastric sensorimotor function is seen in one-fourth of FD cases. HP infection and post-infectious FD are present in 11% and 13% cases, respectively.

Pediatric Solid Gastric Emptying Scintigraphy: Normative Value Guidelines and Nonstandard Meal Alternatives

INTRODUCTION

Adult standards for gastric emptying scintigraphy, including the type of meal and range of normative values for percent gastric emptying, are routinely used in pediatric practice, but to date have not been validated. The purpose of this study is to determine whether the use of adult criteria for gastric emptying scintigraphy is valid for children and whether alternative nonstandard meals can also be offered based on these criteria.

METHODS

This retrospective study analyzed patients (n = 1,151 total) who underwent solid-phase gastric emptying scintigraphy. Patients were stratified into normal and delayed gastric emptying cohorts based on adult criteria, i.e., with normal gastric emptying defined as ≤10% gastric retention at 4 hours. Patients were further stratified based on the type of meal, namely complete or partial adult standard meals or alternative cheese-based meals. Percent gastric retention values at 1, 2, 3, and 4 hours were compared.

RESULTS

The median (95% upper reference limit) percentage gastric retention values for the complete standard meal were 72% (93%) at 1 hour, 39% (65%) at 2 hours, 15% (33%) at 3 hours, and 6% (10 %) at 4 hours. By comparison, the values for cheese-based meals were 60% (87%) at 1 hour, 29% (61%) at 2 hours, 10% (30%) at 3 hours, and 5% (10%) at 4 hours. Consumption of at least 50% of the standard meal yielded similar retention percentages; 68% (89%) at 1 hour, 32% (57%) at 2 hours, 10% (29%) at 3 hours, and 5% (10%) at 4 hours. There were no significant age- or sex-specific differences using the adult criteria.

DISCUSSION

The adult normative standards for gastric emptying scintigraphy are applicable for use in the pediatric population. These same standards can be also be applied to nonstandard meal options, including cheese-based alternative meals and partial standard meals.

Gastric emptying of milk in infants and children up to 5 years of age: normative data and influencing factors

BACKGROUND

Gastric emptying scintigraphy is widely used in infants and children, but there is a lack of age-specific normative data.

OBJECTIVE

The objectives of this retrospective study were: 1) to establish a range of gastric emptying of milk or formula as a surrogate for normal gastric emptying in infants and young children ≤5 years of age, and 2) to investigate the effects of patient age, feeding volume, feeding route and gastroesophageal reflux on gastric emptying.

MATERIALS AND METHODS

The reports of 5,136 gastric emptying studies of children ≤5 years of age performed at Children's National Medical Center from January 1990 to August 2012 were reviewed. Demographic data, 1-h and 3-h gastric emptying values and gastroesophageal reflux status of all patients were stored in a database. Using stringent inclusion and exclusion criteria, the studies of patients as similar to healthy children as possible were selected for this study.

RESULTS

The study group included 2,273 children (57% male) ages 0-59 months (median: 4.6 months). The median 1-h gastric emptying was 43% (interquartile range [IQR] 34-54%). The median 3-h gastric emptying was 91% (IQR 79-98%). Sixty-one percent of patients with 1-h gastric emptying value of <50% had 3-h gastric emptying ≥80%. Gastric emptying was significantly faster in children ≤6 months as compared with all older age groups. In each age group, the median gastric emptying decreased with increasing feeding volume. Gastric emptying was significantly faster in patients fed via combined nasogastric tube and oral routes as compared with those fed exclusively orally. There was no significant difference in gastric emptying of children with and without gastroesophageal reflux.

CONCLUSION

Although there are statistically significant differences in gastric emptying based on age, volume and route of feeding, the data suggest that overall normal liquid gastric emptying in infants and children ≤5 years of age is ≥80% at 3 h. One-hour emptying measurements are not reliable for detecting delayed gastric emptying.

Gastroparesis in the Pediatric Patient: Children Are Not Little Adults

Although the definition of gastroparesis in children is the same as in adults, there are key differences between gastroparesis in these two populations in presentation, diagnosis, treatment and outcomes. Infants and younger children with gastroparesis tend to be male, present with vomiting as their primary symptom and are more likely to experience the resolution of their symptoms over time. Adolescents with gastroparesis tend to be female, present with abdominal pain as their primary symptom and have a less favorable short- and medium-term outcome, sharing some similarities with adults with gastroparesis. Despite the fact that validated diagnostic criteria for gastroparesis are lacking in infants and younger children, these age groups make up nearly half of children with gastroparesis in some studies. The diagnosis and treatment of children with gastroparesis has thus far relied heavily on research studies performed in adults, but it is becoming increasingly clear that gastroparesis in children is a distinct entity and there are limitations to the applicability of data obtained from adults to the care of children.

Chronic vomiting in children: A prospective study reveals rumination syndrome is an important etiology that is underdiagnosed and untreated

BACKGROUND

The diagnosis of rumination syndrome is frequently overlooked, and under-recognized; children are subjected to unnecessary testing and inappropriate treatment for a condition which can be diagnosed clinically and managed easily. In the first ever systematic exploration of this condition from India, we present a prospective study on children with chronic vomiting in which rumination emerged as the predominant cause.

METHODS

This was a prospective study in which all consecutive children (5-18 years) presenting with chronic or recurrent vomiting of at least 2-month duration were enrolled. Clinical history was assessed by a physician-administered questionnaire. All subjects underwent standard testing followed by additional investigations as required. The ROME III criteria were used.

RESULTS

Fifty children (28 boys, age 12.2 + 3 years) were enrolled. Diagnosis was rumination syndrome 30, cyclical vomiting 8, functional vomiting 6, intestinal tuberculosis 4, intestinal malrotation 1, and superior mesenteric artery syndrome 1. Children with rumination syndrome had a relapsing and remitting (12, 40%) or a chronically symptomatic course (18, 60%). These children received incorrect diagnoses (26, 87%) or no diagnosis (3, 10%) and extensive investigation before referral. Before referral, children with rumination syndrome were treated with a median of four drugs (range 1 to 9); two underwent surgery (appendectomy) for their symptoms while one child was subjected to electroconvulsive therapy. Overall, resolution after treatment was seen in 26 (87%) with a relapse in 8 (27%) children.

CONCLUSION

The diagnosis of rumination syndrome is delayed and these children are often inappropriately treated. Therapy in the form of diaphragmatic breathing has a good success rate.

Update on pediatric gastroparesis: A review of the published literature and recommendations for future research

BACKGROUND

Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis.

METHODS

A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility.

KEY RESULTS

Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data.

CONCLUSIONS

Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.

Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: A prospective observational study

BACKGROUND

A light breakfast has been found to empty from the stomach within 4 hours in healthy volunteers.

AIM

The aim of this study was to investigate whether a light breakfast of yoghurt or gruel empties from the stomach within 4 hours, in children scheduled for general anaesthesia.

METHOD

In this observational cohort study, children aged 1-6 years scheduled for elective general anaesthesia were prescribed free intake of yoghurt or gruel 4 hours prior to induction. They were subsequently examined with gastric ultrasound within 4 hours of ingestion. In case of gastric contents, the gastric antral area was measured, and gastric content volume (GCV) was calculated.

RESULTS

Twenty children were included in the study and the ingested amount of gruel or yoghurt ranged 2.5-25 mL kg^-1 . In 15 cases, the stomach was empty with juxtaposed walls and no further measurements were made. In four cases, there was fluid present in the stomach, but the calculated gastric contents were <0.5 mL kg^-1 . One patient had solids in the stomach, and GCV in this patient was calculated to 2.1 mL kg^-1 . The patient with solids present had ingested 25 mL kg^-1 of gruel 4 hours prior to assessment. The planned procedure was therefore delayed 1 hour. There were no cases of pulmonary aspiration or vomiting.

CONCLUSION

A light breakfast 4 hours prior to induction may be considered, but there is need for further studies on safe limits for the volume ingested.

Biopharmaceutical considerations in paediatrics with a view to the evaluation of orally administered drug products - a PEARRL review

OBJECTIVES

In this review, the current biopharmaceutical approaches for evaluation of oral formulation performance in paediatrics are discussed.

KEY FINDINGS

The paediatric gastrointestinal (GI) tract undergoes numerous morphological and physiological changes throughout its development and growth. Some physiological parameters are yet to be investigated, limiting the use of the existing in vitro biopharmaceutical tools to predict the in vivo performance of paediatric formulations. Meals and frequencies of their administration evolve during childhood and affect oral drug absorption. Furthermore, the establishment of a paediatric Biopharmaceutics Classification System (pBCS), based on the adult Biopharmaceutics Classification System (BCS), requires criteria adjustments. The usefulness of computational simulation and modeling for extrapolation of adult data to paediatrics has been confirmed as a tool for predicting drug formulation performance. Despite the great number of successful physiologically based pharmacokinetic models to simulate drug disposition, the simulation of drug absorption from the GI tract is a complicating issue in paediatric populations.

SUMMARY

The biopharmaceutics tools for investigation of oral drug absorption in paediatrics need further development, refinement and validation. A combination of in vitro and in silico methods could compensate for the uncertainties accompanying each method on its own.

Gastroesophageal Reflux Disease and Aerodigestive Disorders

This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance.