asha reflux.ppt
TRANSCRIPT
Gastroesophageal Reflux in Infants
Kathleen Borowitz, MS, CCC-SLPSpeech-Language Pathologist
University of Virginia Children’s Hospital
Disclaimers
Speech-language pathologist, not a pediatrician
Married to pediatric gastroenterologist Mom of a former refluxer
Biases
All babies spit upReflux is over treatedGER is not a disease
Gastroesophageal Reflux
Spontaneous regurgitation of stomach contents upward into the esophagus
GI Tract
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
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
Why does GER happen?
Lower Esophageal Sphincter LES is constantly relaxed LES relaxes at inappropriate time Intragastric pressure increases
sufficiently to overcome LES pressure » >50% of GER episodes
LES function and strength comparable in infants and adults (Hillmeier, 1996)
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
Frequency of GER
>50% of 2 month olds spit up at least twice a day
More common in children with developmental disabilities» Symptoms more severe and
persistent
Frequency of GER
Various studies report findings as high as:
Down syndrome 75% Premature birth 56% Cerebral palsy 75% Autism 74%
Frequency of Infant GERFrequency of Infant GER
0
10
20
30
40
50
60
70
perc
ent o
f inf
ants
0-3 mos 4-6 mos 7-9 mos 10-12 mos
age in months
>1/day
>4/day
a "problem"
adapted from Nelson et al. Arch Pediatr Adolesc Med 151:369, 1997
When do parents When do parents consider GER a consider GER a
problem?problem?
When do parents When do parents consider GER a consider GER a
problem?problem?
the frequency of regurgitation is the frequency of regurgitation is more than once a daymore than once a day
the volume of regurgitation is more the volume of regurgitation is more than 30 cc/daythan 30 cc/day
the baby is fussy or cries excessivelythe baby is fussy or cries excessively there is discomfort with spitting upthere is discomfort with spitting up frequent archingfrequent arching
adapted from Nelson et al. Arch Pediatr Adolesc Med 151:369, 1997
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
Symptoms of GER
Regurgitation and vomiting Feeding problems Pain Irritability Sleep disturbance Respiratory difficulties Growth failure
Symptoms of GER
Feeding Problems
» Dysphagia
» Choking
» Gagging
» Feeding refusal
» Fussiness/pain
Symptoms of GER:Respiratory
Upper airway difficulties Apnea Recurrent croup Recurrent or persistent
laryngitis Subglottic stenosis Stridor
Apnea and GERApnea and GER
“… “… while gastro-oesophageal reflux while gastro-oesophageal reflux and obstructive episodes may co-and obstructive episodes may co-exist . . . decreases in pH in the exist . . . decreases in pH in the lower oesophagus do not usually lower oesophagus do not usually induce either central or obstructive induce either central or obstructive apnoea, and vice versa.”apnoea, and vice versa.”
Paton et al, Eur J Pediatr 149:680, 1990
Apnea and GERApnea and GER
“…“…spontaneous acid refluxes spontaneous acid refluxes extending to the proximal portion of extending to the proximal portion of the oesophagus during sleep are the oesophagus during sleep are usually not temporally related with usually not temporally related with the development of apnoeas or the development of apnoeas or bradycardias.”bradycardias.”
Kahn et al, Eur J Pediatr 151:208, 1992
Apnea and GER
Critical review of GER in preterm infants showed:
1. Apnea is unrelated to GER in most infants
2. Failure to thrive practically does not occur with GER
3. A relationship between GER and chronic airway problems has not yet been confirmed
Poets, Pediatr, 2004
Specificity of Laryngoscopic Specificity of Laryngoscopic Findings attributed to GERFindings 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 2002;16:564
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 2002;112:1019
Do proton pump inhibitors lessen Do proton pump inhibitors lessen laryngeal symptoms attributed to GER?laryngeal symptoms attributed to GER?
adapted from Gatta et al. Alim Pharm Therapeut 2007:25:385-392
““Therapy with a high-dose proton pump inhibitor Therapy with a high-dose proton pump inhibitor is no more effective than placebo in producing is no more effective than placebo in producing
symptomatic improvement or resolution of symptomatic improvement or resolution of laryngo-pharyngeal symptoms.”laryngo-pharyngeal symptoms.”
Symptoms of GER: Respiratory
Lower airway difficulties Chronic cough Chronic or recurrent wheezing Chronic or recurrent
pneumonia
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)
Medical Diagnosis of GER
History, observation, exam Barium swallow/upper GI Gastroesophageal scintigraphy pH probe Upper GI endoscopy
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
Radiologic Diagnosis of Childhood Radiologic Diagnosis of Childhood Gastroesophageal RefluxGastroesophageal Reflux
““The radiologic method used for showing The radiologic method used for showing reflux is designed to be as physiologic as reflux is designed to be as physiologic as possible . . . small vigorous infants are possible . . . small vigorous infants are usually restrained to immobilize the arms usually restrained to immobilize the arms above the head . . . the patient lies in the above the head . . . the patient lies in the right lateral position, and the swallowing right lateral position, and the swallowing mechanism is briefly evaluated . . . the mechanism is briefly evaluated . . . the gastroesophageal junction is carefully gastroesophageal junction is carefully examined while turning the baby gently examined while turning the baby gently from side to side in a supine position or from side to side in a supine position or occasionally rolling him 360occasionally rolling him 360oo.”.”
taken from McCauley et al, AJR 136:47, 1978
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
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
Endoscopy
Small flexible scope passed through mouth» Requires sedation
Allows direct visualization of esophageal mucosa» Presence/severity of esophagitis
Poor sensitivity» < ½ infants w/severe symptoms have
esophagitis
Treatment
Positioning Dietary treatments Feeding schedules Medications Surgery
Treatment:Treatment:PositioningPositioning
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
Treatment:Thickened 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
Treatment: Thickened Feeds
Advantages: Works from the first dose No pharmacologic side effects Negligible cost
How it works: Slows flow=decreases air swallowing Stomach empties faster
Treatment:Thickened 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
Treatment:Prethickened 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
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
Treatment: Formula ChangesFormula Changes
Other than changing the character of the Other than changing the character of the vomitus, formula changes are rarely associated vomitus, formula changes are rarely associated with with lastinglasting significant symptomatic improvement significant symptomatic improvement
Incidence of GER is equivalent in breast and Incidence of GER is equivalent in breast and formula fed infantsformula fed infants
There are some instances of GER due to “food There are some instances of GER due to “food allergy”allergy”
Treatment:Feeding Techniques
Smaller, more frequent feeds and Smaller, more frequent feeds and frequent burping during feedsfrequent burping during feeds
Less in stomach to refluxLess in stomach to reflux» May make the symptoms worse if the May make the symptoms worse if the
child cries more and swallows more child cries more and swallows more airair
» Many infants with GER are difficult to Many infants with GER are difficult to burpburp
Treatment:Medication
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
Treatment: Surgery
Treatment:Fundoplication
Rarely warranted in neurologically normal children» Severe growth failure» Airway obstruction
Postoperative complications» Abdominal distention/discomfort» Retching» Dumping» Solid dysphagia» Decreased swallow frequency
SLP’s 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
Aspiration
Episode in which a foreign substance is inhaled into the lungs
Aspiration
Signs/Symptoms Increased upper airway congestion Strider/hoarseness Apnea/bradycardia Cough/gag Signs of struggle during feeding
Aspiration
Signs of struggle Nares flared Neck extension Arms out Head bobbing Increased respiratory rate Decreased O2 saturation
AspirationAssociated with GER
Cricopharyngeal dysfunction Vocal cord paralysis Neurological disorders Immature neurological system Laryngeal clefts
Laryngeal Cleft
Aspiration:Evaluation
Swallow Safety Cervical auscultation VFSS Fiberoptic endoscopic evaluation of
swallow (FEES ) Blue dye test (trach)
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
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
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
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
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
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
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
Case Study II
Recommended d/c AR and trying regular formula
thickened with rice cereal Fully upright positioning during
feeding
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
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
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
Kathleen Borowitz, MS, CCC-SLPUniversity of Virginia Health
SystemTherapy Services