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GASTROOESOPHAGEAL REFLUX

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Increase GOR in babies who cry excessively. Parents believe they have reflux ... Dysphagia, haematemesis. Melena. Nausea, belching. Arching, bradycardia. Hiccups ... – PowerPoint PPT presentation

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Title: GASTROOESOPHAGEAL REFLUX


1
GASTRO-OESOPHAGEAL REFLUX
  • ANNE ASPIN
  • 2005

2
Douglas (2005)
  • Excessive crying
  • 30 of infants to GP
  • Increase GOR in babies who cry excessively
  • Parents believe they have reflux

3
  • Key factors that impact on infant distress
  • Feeding management
  • Parental responsiveness
  • Sensory nourishment
  • Sleep management

4
Feeding management
  • Frequent feeding
  • Breast or bottle feeding technique
  • Cows milk allergy

5
Parent responsiveness
  • Response depends upon urgency of cry
  • Louder , high pitch scream communication
  • Need prompt response to cues

6
Sensory nourishment
  • Sling / harness
  • Walks
  • Massage
  • Bathing
  • Soft music

7
Sleep management
  • Sleep routine, night, day, quiet time
  • 18.00hrs most increased reflux rythmn
  • Dreizzan et al (1990)

8
Effects of these responses
  • Decreased crying at less than 3-4 mths of age
  • Decreased incidence of GORD once they are older.

9
Health promotion
  • Shenassa et al (2004)
  • Early prevention and health promotion in maternal
    smoking and infantile gastro intestinal
    dysregulation

10
motilin
  • An amino acid hormone produced by the duodenum
    and jejunum mucosa
  • Released every 90 minutes when fasting
  • Vagal nerve stimulation increases the number and
    force of contraction
  • Difficulty with comforting a crying baby may be
    due to cycle of increased gut motility, continual
    crying and higher motilin levels

11
Purpose of study
  • Infants exposed to cigarette smoke is linked to
    elevated blood motilin levels
  • Which is linked to increased risk of
    gastro-intestinal dysregulation including colic
    and acid reflux

12
Method
  • Critical review
  • Epidemiology, Physiologic, Biological evidence
  • Smoking and colic
  • Smoking and motilin levels
  • Motilin and colic

13
Results
  • Six studies
  • Results from five studies shows there is an
    association with maternal smoking and excessive
    crying and intestinal colic
  • Smoking is linked to increased plasma and
    intestinal motilin levels
  • Higher than average level of motilin are linked
    to increased colic

14
A case for left lateral positioning
  • Tobin et al (1997)
  • Prone posture recommended for GOR but associated
    with SID

15
STUDY
  • 24 infants gt 4days, lt5/12 with symptoms GOR
    studies 48hrs PH
  • Randomly assigned prone, supine, left or right
    lateral
  • 1st 24hrs horizontal then 30o head elevation

16
Results
  • GOR significantly less in prone and left lateral
    position than supine and right lateral position
  • Conclusion for this study, elevation may not
    always be of value

17
Carre (1960), Meyers et al (1982)
  • I would disagree.
  • Car seats, elevation of the head of the cot.
  • Risk of slumping- cause raised intra abdominal
    pressure and reflux
  • (Dodds et al 1981, Orenstein et al 1983, Jolley
    et al 1978

18
Back to the drawing board
  • Effect of nursing in the head elevated tilt
    position (15 degree) on the incidence of
    bradycardia and hypoxaemia episodes in the
    preterm infant. (Jennie et al 1997)

19
Method
  • 12 spontaneous breathing preterm infants with
    idiopathic recurrent apnoea studied in a
    randomized controlled crossover trial.
  • 24 hrs prone and horizontal
  • 24 hrs prone 15 degree tilt
  • Position changed 6 hourly randomly

20
Result
  • Improved gastric emptying
  • Improved weight gain
  • Faster gastric emptying on tilt
  • No difference in gastric residuals
  • Some studies show increased apnoea with GOR,
    whereas others do not

21
Are we seeing the light?
  • Ewar et al (1999)
  • Small sample- 18 preterm babies
  • Clinical symptoms of GOR
  • 24 hour lower oesophageal PH monitoring

22
Positions
  • Prone for 8 hours
  • Left lateral for 8 hours
  • Right lateral for 8 hours
  • Result prone and left lateral significantly
    reduce GOR, decrease in number of episodes and
    duration

23
Case history
  • Ex 28/40, stoma for nec
  • Full feeds, 1 kg, wt increasing, 28days old.
  • Laid horizontal, supine, boundaries for
    comfort
  • small vomit, increasing residuals.
  • Chest infection.

24
Case history
  • Term, gastroschisis,
  • 3 hrly feeds, possits,
  • irritable fussy, nurses say he appears hungry one
    hour after feeds, more food?

25
Case history
  • Term baby, meconium ileus, end to end anastomosis
  • Full continuous feeds
  • Feeds changed to three hourly
  • Loose stools
  • Vomiting, sore buttocks
  • Put back to 2 hourly feeds

26
Case history
  • TOF and OA, term, primary anastomosis
  • Full feeds, home
  • Disinterested in feeds
  • Pale, mucousy
  • Stricture
  • Effects on reflux episodes

27
Preterm babies
  • Poets (2004)
  • GOR common in preterm infants (approx 3-5
    episodes per hour)
  • Omari et al (2002) studied 36 infants, 14
    symptomatic. GORD triggered by gastric distension
    and abdominothoracic straining

28
Preterm babies
  • GOR doubled with ng tube in situ
  • GORD is not related to delayed gastric emptying
    so why use prokinetic?

29
Cows milk allergy / GOR
  • CMA
  • Diarrhoea
  • Bloody stools
  • Rhinitis, nasal congestion
  • Constipation
  • Eczema/ dermatitis
  • Lip swelling
  • itching
  • Dysphagia, haematemesis
  • Melena
  • Nausea, belching
  • Arching, bradycardia
  • Hiccups
  • Aspiration, chest infection
  • Stridor, laryngitis

30
Salvatore and Vanderplas (2002)
  • Gastric emptying.
  • Multiple dietary factors- volume, calorie
    density, osmolarity, protein content all effect
    gastric motility

31
  • Type of milk regulates gastric emptying rate,
  • And gastric residual content
  • Salvatore and Vanderplas (2002) reports delayed
    gastric emptying with GORD by causing
    inappropriate relaxation of the lower oesophageal
    sphincter

32
Constipation
  • Formula milk associated with constipation where
    overfeeding occurs.
  • Motility disturbance

33
Anti-reflux procedure
  • Sullivan (1999)
  • 15 - 75 neurologically impaired
  • Gastric dysrythmia
  • Persistant activationof emetic reflex
  • Gastrostomy feeds are efficient and cost
    effective
  • 26 complications, GOR secondary to PEG placement.

34
Nissans Fundoplication
  • Relieves symptoms in more than 80 patients
  • Pearl et al (1990), 234 patients
  • 153 disabled
  • Post op complications 26 NI, 12 others
  • Re operation 19, 5

35
Fankalsrud et al (1998)
  • Retrospective study 7467 patients, 7 large
    children hospital
  • 56 neurologically normal
  • 44 neurologically impaired
  • 40 lt 1 year old
  • Good results 95 NN, 84 NI
  • 4.2 complications as opposed to 12.8

36
So what are we saying?
  • Nurse baby left lateral
  • Small regular feeds
  • Observe behaviour
  • Measure and monitor residuals
  • Crying one hour after feeds may indicate GOR
  • Head tilt at risk infants

37
Position
  • The jury remains out on many aspects
  • Caution when critique literature
  • Treat each baby as individual

38
That is all for now
  • Thank you for listening
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