Gastroesophageal Reflux in Infants

1
Gastroesophageal Reflux in Infants

• Kathleen Borowitz, MS, CCC-SLP
• Speech-Language Pathologist
• University of Virginia Childrens Hospital

2
Disclaimers

• Speech-language pathologist, not a pediatrician
• Married to pediatric gastroenterologist
• Mom of a former refluxer

3
Biases

• All babies spit up
• Reflux is over treated
• GER is not a disease

4
Gastroesophageal Reflux

• Spontaneous regurgitation of stomach contents
  upward into the esophagus

5
GI Tract
6
Normal Physiology

• Pharyngeal phase
• Food moved into upper esophagus
• Esophageal phase
• Esophageal peristalsis actively pushing food down
  into the stomach
• Gastric phase
• Food enters stomach
• Digestive enzymes and acid secreted and
  contractions begin

7
Normal Physiology

• Peristaltic waves of stomach
• mix food w/enzymes and acid
• Force food downward toward stomach outlet
  (pylorus)
• Also forces food upward toward the LES

8
Why does GER happen?

• Lower Esophageal Sphincter
• LES is constantly relaxed
• LES relaxes at inappropriate time
• Intragastric pressure increases sufficiently to
  overcome LES pressure
• gt50 of GER episodes
• LES function and strength comparable in infants
  and adults (Hillmeier, 1996)

9
Why does GER happen?

• Modern Feeding Practices
• Large volume feeds
• Delayed introduction of solids
• Prolonged recumbent periods
• Increased use of seating devices increased
  intraabdominal pressure

10
Frequency of GER

• gt50 of 2 month olds spit up at least twice a day
• More common in children with developmental
  disabilities
• Symptoms more severe and persistent

11
Frequency of GER

• Various studies report findings as high as
• Down syndrome 75
• Premature birth 56
• Cerebral palsy 75
• Autism 74

12
Frequency of Infant GER
adapted from Nelson et al. Arch Pediatr Adolesc
Med 151369, 1997
13
When do parents consider GER a problem?
14
When do parents consider GER a problem?

• the frequency of regurgitation is more than once
  a day
• the volume of regurgitation is more than 30
  cc/day
• the baby is fussy or cries excessively
• there is discomfort with spitting up
• frequent arching

adapted from Nelson et al. Arch Pediatr Adolesc
Med 151369, 1997
15
Infant GER

• Begins to decrease in frequency near 6 months of
  age
• Sitting, increased truncal tone
• Further decrease in frequency near 12 months of
  age
• Walking, pulling to stand
• Typically GER completely abates by 24 months of
  age

16
Symptoms of GER

• Regurgitation and vomiting
• Feeding problems
• Pain
• Irritability
• Sleep disturbance
• Respiratory difficulties
• Growth failure

17
Symptoms of GER

• Feeding Problems
• Dysphagia
• Choking
• Gagging
• Feeding refusal
• Fussiness/pain

18
Symptoms of GERRespiratory

• Upper airway difficulties
• Apnea
• Recurrent croup
• Recurrent or persistent laryngitis
• Subglottic stenosis
• Stridor

19
Apnea and GER

• while gastro-oesophageal reflux and
  obstructive episodes may co-exist . . .
  decreases in pH in the lower oesophagus do not
  usually induce either central or obstructive
  apnoea, and vice versa.

Paton et al, Eur J Pediatr 149680, 1990
20
Apnea and GER

• spontaneous acid refluxes extending to the
  proximal portion of the oesophagus during sleep
  are usually not temporally related with the
  development of apnoeas or bradycardias.

Kahn et al, Eur J Pediatr 151208, 1992
21
Apnea and GER

• Critical review of GER in preterm infants showed
• Apnea is unrelated to GER in most infants
• Failure to thrive practically does not occur with
  GER
• A relationship between GER and chronic airway
  problems has not yet been confirmed
• Poets, Pediatr, 2004

22
Specificity of Laryngoscopic Findings attributed
to GER

• 105 healthy asymptomatic adults underwent
  videotaped flexible laryngoscopy
• 86 had findings attributed to reflux (many of
  the findings are considered pathognomonic for
  GERD)
• Hicks et al. J Voice 200216564
• 120 videotaped laryngeal examinations were scored
  for signs of GER by 5 ENT physicians
• poor correlation of reflux associated changes
• poor inter-rater reliability
• Branski et al. Laryngoscope 20021121019

23
Do proton pump inhibitors lessen laryngeal
symptoms attributed to GER?
Therapy with a high-dose proton pump inhibitor
is no more effective than placebo in producing
symptomatic improvement or resolution of
laryngo-pharyngeal symptoms.
adapted from Gatta et al. Alim Pharm Therapeut
200725385-392
24
Symptoms of GER Respiratory

• Lower airway difficulties
• Chronic cough
• Chronic or recurrent wheezing
• Chronic or recurrent pneumonia

25
Symptoms of GER

• Medications for asthma may contribute to
  symptoms of GER
• Decrease LES tone (methylzanthines)
• Increase gastric acid secretion (aminophylline)
• Cause chronic cough (ACE inhibitors, inhaled
  corticosteriods)

26
Medical Diagnosis of GER

• History, observation, exam
• Barium swallow/upper GI
• Gastroesophageal scintigraphy
• pH probe
• Upper GI endoscopy

27
Barium Swallow

• Videofluoroscopic study
• Patient fed barium
• Followed down esophagus, through LES and into
  stomach
• Reflux graded 1 to 5
• 5 reflux up into proximal esophagus w/aspiration
• Poor sensitivity and specificity

28
Radiologic Diagnosis of Childhood
Gastroesophageal Reflux

• The radiologic method used for showing reflux is
  designed to be as physiologic as possible . . .
  small vigorous infants are usually restrained to
  immobilize the arms above the head . . . the
  patient lies in the right lateral position, and
  the swallowing mechanism is briefly evaluated . .
  . the gastroesophageal junction is carefully
  examined while turning the baby gently from side
  to side in a supine position or occasionally
  rolling him 360o.

taken from McCauley et al, AJR 13647, 1978
29
GE Scintigraphy

• Patient fed technetium mixed with formula
• Gamma camera follows the labeled milk through
  GI tract
• Less radiation than barium swallow
• May be useful in detecting pulmonary aspiration
• Poor sensitivity and specificity

30
pH Probe

• Flexible pH sensor threaded down nose to
  esophagus to lower esophagus
• Detects acid from stomach when refluxed into
  esophagus over 24 h
• Detects frequency of episodes and length of time
  to clear
• Cannot detect reflux immediately after feeding

31
Endoscopy

• Small flexible scope passed through mouth
• Requires sedation
• Allows direct visualization of esophageal mucosa
• Presence/severity of esophagitis
• Poor sensitivity
• lt ½ infants w/severe symptoms have esophagitis

32
Treatment

• Positioning
• Dietary treatments
• Feeding schedules
• Medications
• Surgery

33
TreatmentPositioning

• Feed in upright position
• Avoid frequent or rapid changes in position
  during feeding
• Avoid positions that increase intra-abdominal
  pressure (infant seats, swing seats)
• Head of bed elevated

34
TreatmentThickened Feeds

• Thickening formula or breast milk with rice
  cereal
• Decreased episodes of regurgitation
• Decreased time crying
• Increased time asleep
• Reduced choking/coughing/gagging with feedings
• Orenstein, J Pediatr 1987

35
Treatment Thickened Feeds

• Advantages
• Works from the first dose
• No pharmacologic side effects
• Negligible cost
• How it works
• Slows flowdecreases air swallowing
• Stomach empties faster

36
TreatmentThickened Feeds

• Recommended amount
• ½ teaspoon rice cereal per 30cc formula or breast
  milk
• Can increase up to 1 ½ teaspoons
• Others recommend as much as 1 tablespoon per 30cc

37
TreatmentPrethickened Formulas

• Enfamil AR
• Substitutes approximately 30 of lactose with
  rice starch
• No thicker in bottle
• Once pH drops below 5.5 in the stomach viscosity
  of formula rises

38
Treatment Prethickened Formulas

• Useful for infants with weak suck or decreased
  endurance
• Cleft palate
• Congenital heart disease
• Prematurity
• Does not decrease rate of flow from bottle

39
Treatment Formula Changes

• Other than changing the character of the vomitus,
  formula changes are rarely associated with
  lasting significant symptomatic improvement
• Incidence of GER is equivalent in breast and
  formula fed infants
• There are some instances of GER due to food
  allergy

40
TreatmentFeeding Techniques

• Smaller, more frequent feeds and frequent
  burping during feeds
• Less in stomach to reflux
• May make the symptoms worse if the child cries
  more and swallows more air
• Many infants with GER are difficult to burp

41
TreatmentMedication

• Antacids
• Neutralize acid
• H2 blockers (Zantac, Pepcid)
• Decrease acid production
• PPI (Previcid, Prilosec, Nexium)
• Totally block production of acid
• Antihistamine effect- may help if allergy
  component
• Prokinetic agents (Reglan, erythromicin)
• Make stomach empty more quickly

42
Treatment Surgery
43
TreatmentFundoplication

• Rarely warranted in neurologically normal
  children
• Severe growth failure
• Airway obstruction
• Postoperative complications
• Abdominal distention/discomfort
• Retching
• Dumping
• Solid dysphagia
• Decreased swallow frequency

44
SLPs Role in Diagnosis and Treatment

• Recognize signs/symptoms of GER during feeding
• Recognize signs/symptoms of aspiration associated
  with GER
• Consider causes of aspiration with GER
• Give suggestions for further evaluation and
  non-medical management

45
Aspiration

• Episode in which a foreign substance is inhaled
  into the lungs

46
Aspiration

• Signs/Symptoms
• Increased upper airway congestion
• Strider/hoarseness
• Apnea/bradycardia
• Cough/gag
• Signs of struggle during feeding

47
Aspiration

• Signs of struggle
• Nares flared
• Neck extension
• Arms out
• Head bobbing
• Increased respiratory rate
• Decreased O2 saturation

48
AspirationAssociated with GER

• Cricopharyngeal dysfunction
• Vocal cord paralysis
• Neurological disorders
• Immature neurological system
• Laryngeal clefts

49
Laryngeal Cleft
50
AspirationEvaluation

• Swallow Safety
• Cervical auscultation
• VFSS
• Fiberoptic endoscopic evaluation of swallow (FEES
  )
• Blue dye test (trach)

51
Case Study I

• History
• 2 week old male, 38 weeks EGA w/duodenal atresia
  s/p repair on DOL 1
• Poor PO intake, difficult to feed

52
Case Study I

• Evaluation
• Appearance/oral structures and oral reflexes WFL
• NGT dependent initiates feeds well, but quickly
  shows distress
• Increased forward liquid loss
• Pulling off nipple
• Extension/arching/facial grimacing
• 15-20 cc per feeding trial

53
Case Study I

• Impression
• Experiencing esophageal dysmotility and/or GER
  while feeding
• UGI study confirmed significant GER
• Recommended
• d/c PPI and initiate trial of Enfamil AR for all
  feeds

54
Case Study I

• Result
• Began taking 60-70 cc per feed with sustained,
  rhythmical suck
• No signs of distress/discomfort during feeds
• Continued occasional small reflux episodes

55
Case Study II

• History
• 3 month old former 25 week premie, H/O
  intubation, RDS and GER
• Home from NICU 2 weeks on Enfamil AR
• Readmitted due to blue spells and slowed
  breathing during feeding

56
Case Study II

• Evaluation
• Proptosis and wide, blunted tongue
• Mildly hoarse voice and stridor
• Intact oral reflexes w/vigorous suck
• Very rapid intake w/frequent decreases in O2
  saturations and heart rate and pulling off nipple
  for catch-up breathing

57
Case Study II

• Impression
• Voracious feeder w/poor ability to coordinate
  suck-swallow-breathe
• Signs/symptoms of reflux both during and after
  feeds
• AR may have helped somewhat with GER but not with
  suck-swallow coordination or possible air
  swallowing

58
Case Study II

• Recommended
• d/c AR and trying regular formula thickened with
  rice cereal
• Fully upright positioning during feeding

59
Case Study II

• Result
• Sustained suck with no signs of distress or
  pulling off nipple
• Calmer state
• Able to maintain O2, HR and RR through full
  feeding

60
Summary

• GER is very common in infants
• Most children outgrow reflux by 24 months
• Serious complications of GER are rare
• The role of GER in the etiology of apnea, asthma
  and upper airway symptoms is unclear

61
Summary

• Try simple treatments for GER first
• Infants with normal anatomy and intact
  neurological systems protect their airway
• SLPs can recognize signs and symptoms of GER and
  aspiration associated with GER during feeding

62
Kathleen Borowitz, MS, CCC-SLPUniversity of
Virginia Health SystemTherapy Services434.924.82
45kcb8t_at_virginia.edu