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Gastrointestinal Motility and Sensory Abnormalities May Contribute to Food Refusal in Medically Fragile Toddlers

Zangen, Tsili*; Ciarla, Carla; Zangen, Samuel*; Di Lorenzo, Carlo; Flores, Alex F.§; Cocjin, Jose; Reddy, Sarabudla Narasimha; Rowhani, Anita; Schwankovsky, Lenore; Hyman, Paul E.

Journal of Pediatric Gastroenterology and Nutrition: September 2003 - Volume 37 - Issue 3 - p 287-293
Original Articles—Gastroenterology

Background In chronically ill children who refuse to eat, surgery to correct anatomic problems and behavioral treatments to overcome oral aversion often succeed. A few patients fail with standard treatments. The aims of the study were to: 1) investigate motility and gastric sensory abnormalities and 2) describe treatment that was individualized based on pathophysiology in children who failed surgery and behavioral treatments.

Methods We studied 14 patients (age 1.5–6; mean 2.5; M/F: 7/7). All had a lifelong history of food aversion and retching or vomiting persisting after feeding therapy and fundoplication. All were fed through gastrostomy or gastro-jejunostomy tubes. We studied esophageal and antroduodenal manometry, and gastric volume threshold for retching. We identified when gastric antral contractions were associated with retching and pain. A multidisciplinary treatment program included a variable combination of continuous post-pyloric feedings, drugs to decrease visceral pain, drugs for motility disorders, and behavioral, cognitive, and family therapy. We interviewed parents 2–6 months following testing to evaluate symptoms, mode of feeding and emotional health.

Results We found a motility disorder alone in 2, decreased threshold for retching alone in 5 and both motility and sensory abnormalities in 7. After treatment, 6 of 14 (43%) began eating orally and 80% had improved emotional health. Retching decreased from 15 episodes per day to an average of 1.4 per day (p <0.01).

Conclusions Upper gastrointestinal motor and/or sensory disorders contributed to reduced quality of life for a majority of children and families with persistent feeding problems. A multidisciplinary approach improved symptoms and problems in these children

Department of Pediatrics, Kansas University Medical Center; *Pediatric Gastroenterology and Nutrition, Schneider Children's Medical Center, Israel; †Pediatric unit, Santa Maria delle Grazie Hospital, Naples, Italy; ‡GI Department, Children's Hospital of Pittsburgh, PA; §Pediatric Gastroenterology, Newton-Wellesley Hospital, Newton, MA

Received October 11, 2001; accepted March 15, 2003.

Address correspondence and reprint requests to Dr. Tsili Zangen, Department of Pediatric Gastroenterology and Nutrition, Schneider Children's Medical Center of Israel, 14 Kaplan street, Petah-Tiqva, Israel, (e-mail:

© 2003 Lippincott Williams & Wilkins, Inc.