Delayed Gastric Emptying in Children: Our Family's Experience
Delayed Gastric Emptying in Children
What is Delayed Gastric Emptying?
Delayed gastric emptying (DGE), or gastroparesis, is also known as a "paralyzed stomach." The stomach is unable to empty its contents at a normal rate, though there is no physical obstruction to slow the rate of emptying.
The condition may coincides with severe gastroesopageal acid reflux disease, or GERD. When the stomach is unable to empty its contents, the food and acid may travel back up the esophagus. This may lead to vomiting.
Our son has severe GERD/DGE and had surgery performed to stop the unrelenting acid reflux. While his Nissen fundoplication stopped the reflux, he still suffers the effects of the delayed emptying. He has struggled to maintain his own growth curve and has been labeled Failure to Thrive. He currently receives supplemental feeds through a gastrostomy tube at night. With the supplemental nutrition, he should be able to thrive and grow once more.
Nausea and Delayed Gastric Emptying
- Early satiety: Children will feel "full" after eating only a few bites.
- Bloating: The abdomen will bloat and become round and hard.
- Vomiting: Children with DGE will often vomit, and the vomit may contain undigested food.
- Nausea: A child will often complain of feeling "sick."
- Weight loss: Children may fall off their growth curve, and become "failure to thrive."
Causes of Delayed Gastric Emptying
In adults, the most common cause of gastroparesis is diabetes. This is not the case with children, who often have an idiopathic (unknown) cause for the delayed emptying. The causes for DGE in children include:
- Neuromuscular diseases, including Mitochondrial Disease
- Cerebral Palsy
Some children will have gastroparesis following a bout of rotavirus or other viral infection. In these cases, the gastroparesis nearly always resolves with time,and the child will resume normal eating habits once the body has fully recovered. Other causes of DGE are longer lasting (and may even be life-long).
In the case of our son, the cause of the DGE is unknown. He has several other medical issues, including laryngomalacia, hearing loss, obstructive sleep apnea, severe GERD, mild hypotonia, and amblyopia.
Gastric Emptying Scan
Gastric Emptying Study
A Gastric Emptying Study or Gastric Emptying Scan is a test to diagnose delayed gastric emptying. Unfortunately, there are many methods for performing the test, and even different cut-offs for determining slow digestion.
A small amount of radioactive isotope is placed in the child's food. Some hospitals will perform a "milk scan" and place the tracer in the child's milk. Others will have the child eat eggs or oatmeal, which has a known digestion time. Still other hospitals will have you bring the child's own food and will place the isotope in the food or drink you provide.
Once the child has consumed the labeled food, he will be placed onto a table and a special "camera" will be placed over his abdomen. Images of the tracer will be taken every few seconds for an hour (or two hours, depending on the hospital). The percentage of food emptied will be calculated.
The cut-offs vary by hospital, though generally an emptying time worse than 30-35% after an hour is considered delayed emptying. Our own son had a gastric emptying rate of 27% after an hour at the age of two. As his bloating has increased and his food consumption has decreased, another GES will be performed soon.
Antro-Duodenal Motility Study
Some children with severe gastroparesis may also have abnormal intestinal motility. A test called an antro-duodenal motility study may be performed for these children. There are very few "motility centers" able to perform this test in children at the current time, so this test is not commonly used.
A small catheter is passed through the nose and into the stomach and duodenum (the first part of the small intestine). The catheter will be connected to a computer and a technician will flush it with water. The computer will record stomach contractions while the stomach is at rest and after a special meal has been eaten. A trial of erythromycin or other medication may be used to determine if this aids the stomach's ability to contract. This test takes 6-8 hours to complete and is a difficult procedure for most children.
This test is valuable because it can identify whether the motility problem is caused by a muscular disorder or neurological disorder.
SmartPill for Motility Testing
SmartPill Diagnostic Device
SmartPill Corporation makes a wireless motility capsule that can determine the strength of muscle contractions, pH, and temperature. This "pill" is swallowed and will transmit data for up to five days, and provides information about the functionality of the entire GI tract. The patient wears a data collection device until the pill has passed. Once the pill has passed from the body, the data is collected and analyzed. The SmartPill is an alternative to a gastric emptying scan.
High Fat Foods are Not Tolerated
Delayed Gastric Emptying Diet
All children with gastroparesis will benefit from eating several small meals throughout the day. The following food choices will aid digestion:
- Eat cooked fruits and vegetables, as this reduces the fiber content.
- Avoid foods high in fiber, like broccoli.
- Eat low fat foods, as fat slows digestion.
- Drink water with meals.
Each child with DGE will have a different treatment plan, so consult with your child's' GI specialist to determine proper food choices for your child. Some children with severe gastroparesis are unable to take any food by mouth.
DGE Treatment Poll
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Gastric Pacemaker Success Story
The treatment options for gastroparesis vary by the severity of the condition. A low fat diet should be followed by all patients with delayed emptying, and the following pharmaceuticals may be used:
Erythromycin is an antibiotic that stimulates stomach contractions. It has variable success - it works well for some children, and is not effective for others.
Reglan (Metroclopramide) is a motility drug used in the United States. This drug has a black-box warning from the FDA, as the drug can cross the blood-brain barrier. A rare side effect is a permanent condition called Tardive Dyskinesia. For this reason, the drug has fallen out of favor.
Domperidone: Not approved for the treatment of motility disorders in the United States, this drug is widely used in Canada and Europe. This drug does not cross the blood-brain barrier and can be a very effective treatment for gastroparesis.
Gastric pacemakers are not often used in children, though the device has been extremely successful for some advanced cases of DGE that have not benefited from more traditional therapies. Candidates for a gastric pacemaker cannot obtain benefit from other, more standard treatments for gastroparesis.
Overnight Feeds via G-Tube
Enteral Feeding for Delayed Gastric Emptying
Many children with DGE suffer from early satiety (feeling full despite eating very little), and cannot maintain their weight or growth curve. These children are considered organic "failure to thrive," and must receive nutritional support to grow.
Children who require nutritional support will often have a gastrostomy tube (G-tube) placed. As children who have gastroparesis cannot tolerate large quantities of food at one time, bolus feeding is generally not tolerated. Children may be fed with a pump that delivers small quantities of formula on a continuous basis. Some children may require continuous feeds over a 24 hour cycle, while others will need nighttime supplementation.
For children with extremely severe gastroparesis, the stomach will not tolerate any food at all. When this happens, a jejunal tube (or J-tube) may be required. This tube has a port on the stomach, but the tube extends into the intestine. This bypasses the non-functioning stomach entirely. J-tube feeds must be delivered by pump in small aliquots, so all children with J-tubes require continuous feeds.
The formula used for feeding will vary - some children cannot tolerate common formulas like Pediasure, and will require a pre-digested formula to support nutritional needs.
Our son's gastroparesis causes him to feel full too early, but he is still able to eat food during the daytime. He currently takes in approximately half of his required caloric intake by mouth, and the rest of his calories are delivered by a pump overnight. He had a Mic-Key g-tube placed along with a fundoplication at the age of 4 years, and the overnight feeds go through his g-tube with the aid of a Kangaroo Joey pump.
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