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

434.924.8245kcb8t@virginia.edu