Journal of Pediatric Gastroenterology & Nutrition:
Letter To The Editor
Israel, David M. M.D., F.R.C.P.(C.); Mahdi, Gamal M.B.B.Ch., M.R.C.P.(I.)
To the Editor: “Nonorganic failure to thrive” (NOFTT) is a catchall term implying that the cause for FTT is external to the child; it includes up to 45% of all FTT cases (1). Tolia's article (2) describes seven infants and children who underwent intensive evaluation to exclude organic as well as psychosocial causes for their FTT. We have all shared this experience and often face the difficult treatment choices as discussed in the accompanying editorial (3).
Over the last 4 years, we have observed four children aged 2 months to 3 years (mean, 1.4 yrs) with FTT and poor intake, vomiting, or food refusal, as aptly described by English (1) and Tolia (2). The only abnormal finding in these four children's evaluation was markedly delayed gastric emptying. They all underwent a gastric drainage procedure; two children had pyloroplasty and two had through-the-scope (TTS) pyloric balloon dilatation. All four children responded with a dramatic change in food intake and decreased vomiting. One of the children who underwent TTS balloon dilatation had good but transient improvement that responded permanantly to pyloroplasty. The mean preprocedure gastric emptying at 90 min was 27%; the mean postprocedure value was 70%. At followup of 1.2-5 years (mean, 2.5) they all had significant catch-up growth.
Delayed gastric emptying may contribute to an increase in gastroesophageal reflux (GER) (4-6), but gastric drainage has been shown to improve symptoms and oral intake in carefully selected patients (5,6). Cholecystokinin (CCK) modulates gastric emptying in response to food and may also affect appetite (7-9). CCK contracts the pylorus and decreases intragastric pressure in the body of the stomach, which could lead to delayed gastric emptying. Pyloroplasty and pyloric dilatation may relieve early satiety and delayed gastric emptying by limiting the ability of the pylorus to respond to CCK.
It is therefore important to realize that delayed gastric emptying can lead to poor feeding and FTT. Assessment of gastric emptying should be part of the evaluation of infants and children with vomiting or early satiety and food avoidance. Pyloroplasty and TTS pyloric balloon dilatation may be helpful in the management of these children. Further studies are required to better understand the role of gastric emptying in FTT and the best ways to treat it.
David M. Israel, M.D., F.R.C.P.(C.); Gamal Mahdi, M.B.B.Ch., M.R.C.P.(I.)
Division of Gastroenterology
BC Children's Hospital
Vancouver, British Columbia
1. English PC. Failure to thrive without organic reason. Pediatr Ann
2. Tolia V. Very early onset nonorganic failure to thrive in infants. J Pediatr Gastroenterol Nutr
3. Farrell MK. Difficult feeders: intervene or watch. J Pediatr Gastroenterol Nutr
4. Hillemeier AC, Lange R, McCallum R, et al. Delayed gastric emptying in infants with gastroesophageal reflux. J Pediatr
5. Byrne WJ, Kangarloo H, Ament ME, et al. “Antral dysmotility,” an unrecognized cause of chronic vomiting during infancy. Ann Surg
6. Fonkalsrud EW, Ament ME, Vargas J. Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children. Am J Surg
7. Meyer JH. Motility of the stomach and the gastroduodenal junction. In: Johnson LR, ed. Physiology of the gastrointestinal tract
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9. Baile CA, McLaughlin CL, Della-Fera MA. Role of cholecystokinin and opioides in control of food intake. Physiol Rev