Gastroesophageal Reflux in Infants. Kathleen Borowitz, MS, CCC-SLP Speech-Language Pathologist University of Virginia Children s Hospital

Transcription

1 Gastroesophageal Reflux in Infants Kathleen Borowitz, MS, CCC-SLP Speech-Language Pathologist University of Virginia Children s 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» >50% 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 >50% 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 70 percent of infants >1/day >4/day a "problem" 0-3 mos 4-6 mos 7-9 mos mos age in months adapted from Nelson et al. Arch Pediatr Adolesc Med 151:369, 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 151:369, 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 GER: Respiratory 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 coexist... 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 149:680, 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 151:208, 1992

21 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

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 2002;16: 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

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 2007:25:

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 360 o. taken from McCauley et al, AJR 136:47, 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» < ½ infants w/severe symptoms have esophagitis

32 Treatment Positioning Dietary treatments Feeding schedules Medications Surgery

33 Treatment: Positioning Feed in upright position Avoid frequent or rapid changes in position during feeding Avoid positions that increase intraabdominal pressure (infant seats, swing seats) Head of bed elevated

34 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

35 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

36 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

37 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

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 Treatment: Feeding 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 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

42 Treatment: Surgery

43 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

44 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

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 Aspiration: Evaluation 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» 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 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-SLP University of Virginia Health System Therapy Services