Treatment eliminates rumination in developmentally delayed children

Last Updated: 2015-06-29

By Megan Brooks

NEW YORK (Reuters Health) - Rumination syndrome in developmentally delayed children can be eliminated using gastrojejunal tube feedings and bad-tasting food, according to two case reports.

Rumination syndrome is characterized by effortless regurgitation of food, with subsequent spitting out or rechewing and reswallowing. Many children with developmental delay find rumination pleasurable and stimulating. And while it doesn't really harm the child, it's hard on the caregiver and may make social interaction tough.

Treatment for rumination typically involves changing the diet (increasing calories or withholding liquids) or psychological interventions. But Dr. Paul E. Hyman, chief of pediatrics at Children's Hospital of New Orleans, and colleagues had another idea.

They hypothesized that rumination would end if the stomach remained empty. It worked in two nonambulatory, nonverbal 4-year-old children with a history of frequent daily rumination. One child ruminated an estimated 30 times a day.

In these two children, a gastrojejunostomy tube was placed and the children were fed by continuous drip during the day to suppress hunger. They took no food or drink by mouth. In both children, rumination was reduced to three to five times daily but not eliminated.

Adding unpleasant tasting substances (N-acetylcysteine or cayenne pepper-based hot sauce) through the gastrostomy tube every four hours while the children were awake did eliminate rumination.

"Within one week of adding the unpalatable substances, rumination ceased. After two months of no rumination, one mother restarted oral feeding. There was no recurrence of rumination, and three months after gastrojejunal tube placement, the tube was removed. In one year of follow-up, rumination did not recur. The second mother was pleased with the outcome with jejunal feedings and chose not to resume oral feedings," the clinicians report online June 29 in Pediatrics.

In email to Reuters Health, Dr. Hyman said, "It would be wonderful if we could do a case-controlled trial of the method, but no one gastroenterologist sees enough of these children to do it. It would take a multicenter collaboration. I believe that it is appropriate in selected patients like the ones that I reported."

A related report in Pediatrics from pediatricians in Canada provides a look at family experiences with gastrostomy tube feedings in children with neurologic impairment through a systematic review of 13 relevant studies.

Deciding to place a gastrostomy tube in a child with neurologic impairment is a tough decision, one that has "broad-reaching implications" for children and their families, write Dr. Katherine Nelson of the Hospital for Sick Children in Toronto and colleagues. "There are physical, emotional, and relational challenges and benefits for the child, the parents, and the family unit."

For example, parents reported that tube feedings had significant benefits on their children's weight and happiness, improved the caregiver's quality of life, and the family's flexibility. Among the challenges identified, "increased care needs, new stresses for the parents, and family burdens from increased utilization of health services."

Placement of a gastrostomy tube also impacts relationships within and outside the family. "They change the ease and comfort with which the child, and by extension the family, navigates life outside the home. They also increase dependency in the relationship between parents and health care providers," the authors write. For some families, tube feeding may be easier than oral feeding, but for others, tube feeding may be tougher, their review found.

Dr. Nelson and colleagues note that a 2014 clinical report from the American Academy of Pediatrics highlights the complexity considerations that need to be addressed when making decisions about long-term gastrostomy tube feeding in children with disabilities. (http://bit.ly/1QYTFSo)

"Our study further adds to the report's findings by systematically identifying and thoroughly describing themes relevant to the child, parent, and family experience that should be part of clinical conversations before and after placement of a G-tube," they conclude.

Dr. Nelson added in email to Reuters Health, "We know that families often struggle with the decision to place a feeding tube. It's easier for health care providers to focus on the physical benefits of the tube, like improved growth, without fully considering other important aspects of the decision for families and the impact the feeding tube can have on their day-to-day lives. We have an opportunity as health care providers to discuss with the family some of the challenges they might face in advance and figure out together how those challenges could be addressed. Our hope is that this paper will help guide conversations between clinicians and families when considering inserting a feeding tube."

The studies had commercial funding and the authors declared no conflicts of interest.

SOURCE: http://bit.ly/1U0oRQh and http://bit.ly/1LxSlkK

Pediatrics 2015.