GASTRO-OESOPHAGEAL GASTRO-OESOPHAGEAL REFLUXREFLUX

ANNE ASPINANNE ASPIN

20102010

Douglas (2005)Douglas (2005)

Excessive cryingExcessive crying 30% of infants to 30% of infants to

GPGP Increase GOR in Increase GOR in

babies who cry babies who cry excessivelyexcessively

Parents believe Parents believe they have refluxthey have reflux

Key factors that impact on infant Key factors that impact on infant distressdistress

Feeding managementFeeding management Parental responsivenessParental responsiveness Sensory nourishmentSensory nourishment Sleep managementSleep management

Feeding managementFeeding management

Frequent feedingFrequent feeding Breast or bottle feeding techniqueBreast or bottle feeding technique Cows milk allergyCows milk allergy

Parent responsivenessParent responsiveness

Response depends upon urgency of Response depends upon urgency of crycry

Louder , high pitch scream – Louder , high pitch scream – communicationcommunication

Need prompt response to cuesNeed prompt response to cues

Sensory nourishmentSensory nourishment

Sling / harnessSling / harness WalksWalks MassageMassage BathingBathing Soft musicSoft music

Sleep managementSleep management

Sleep routine, night, day, quiet timeSleep routine, night, day, quiet time 18.00hrs most increased reflux 18.00hrs most increased reflux

rythmnrythmn

Dreizzan et al (1990)Dreizzan et al (1990)

Effects of these Effects of these responsesresponses

Decreased crying at less than 3-4 Decreased crying at less than 3-4 mths of agemths of age

Decreased incidence of GORD once Decreased incidence of GORD once they are older.they are older.

Health promotionHealth promotion

Shenassa et al Shenassa et al (2004)(2004)

Early prevention Early prevention and health and health promotion in promotion in maternal smoking maternal smoking and infantile and infantile gastro intestinal gastro intestinal dysregulationdysregulation

motilinmotilin

An amino acid hormone produced by An amino acid hormone produced by the duodenum and jejunum mucosathe duodenum and jejunum mucosa

Released every 90 minutes when fastingReleased every 90 minutes when fasting Vagal nerve stimulation increases the Vagal nerve stimulation increases the

number and force of contractionnumber and force of contraction

Difficulty with comforting a crying baby Difficulty with comforting a crying baby may be due to cycle of increased gut may be due to cycle of increased gut motility, continual crying and higher motility, continual crying and higher motilin levelsmotilin levels

Purpose of studyPurpose of study

Infants exposed to cigarette smoke Infants exposed to cigarette smoke is linked to elevated blood motilin is linked to elevated blood motilin levelslevels

Which is linked to increased risk of Which is linked to increased risk of gastro-intestinal dysregulation gastro-intestinal dysregulation including colic and acid refluxincluding colic and acid reflux

MethodMethod

Critical review Critical review - Epidemiology, Physiologic, Epidemiology, Physiologic,

Biological evidence Biological evidence

1.1. Smoking and colicSmoking and colic

2.2. Smoking and motilin levelsSmoking and motilin levels

3.3. Motilin and colic Motilin and colic

ResultsResults

Six studiesSix studies Results from five studies shows there Results from five studies shows there

is an association with maternal is an association with maternal smoking and excessive crying and smoking and excessive crying and intestinal colicintestinal colic

Smoking is linked to increased plasma Smoking is linked to increased plasma and intestinal motilin levelsand intestinal motilin levels

Higher than average level of motilin Higher than average level of motilin are linked to increased colicare linked to increased colic

A case for left lateral A case for left lateral positioningpositioning

Tobin et al (1997)Tobin et al (1997)

Prone posture Prone posture recommended for recommended for GOR but GOR but associated with associated with SIDSID

STUDYSTUDY

24 infants > 4days, 24 infants > 4days, <5/12 with <5/12 with symptoms GOR symptoms GOR studies 48hrs PHstudies 48hrs PH

Randomly assigned Randomly assigned prone, supine, left prone, supine, left or right lateralor right lateral

11stst 24hrs horizontal 24hrs horizontal then 30o head then 30o head elevationelevation

ResultsResults

GOR significantly GOR significantly less in prone and less in prone and left lateral position left lateral position than supine and than supine and right lateral right lateral positionposition

Conclusion for this Conclusion for this study, elevation study, elevation may not always be may not always be of valueof value

Carre (1960), Meyers et Carre (1960), Meyers et al (1982)al (1982)

I would disagree.I would disagree. Car seats, elevation Car seats, elevation

of the head of the of the head of the cot.cot.

Risk of slumping- Risk of slumping- cause raised intra cause raised intra abdominal pressure abdominal pressure and refluxand reflux

(Dodds et al 1981, (Dodds et al 1981, Orenstein et al 1983, Orenstein et al 1983, Jolley et al 1978Jolley et al 1978

Back to the drawing Back to the drawing boardboard

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

MethodMethod

12 spontaneous breathing preterm 12 spontaneous breathing preterm infants with idiopathic recurrent infants with idiopathic recurrent apnoea studied in a randomized apnoea studied in a randomized controlled crossover trial.controlled crossover trial.

24 hrs prone and horizontal24 hrs prone and horizontal 24 hrs prone 15 degree tilt 24 hrs prone 15 degree tilt

Position changed 6 hourly randomlyPosition changed 6 hourly randomly

ResultResult

Improved gastric emptyingImproved gastric emptying Improved weight gainImproved weight gain Faster gastric emptying on tiltFaster gastric emptying on tilt No difference in gastric residualsNo difference in gastric residuals Some studies show increased Some studies show increased

apnoea with GOR, whereas others do apnoea with GOR, whereas others do notnot

Are we seeing the light?Are we seeing the light?

Ewar et al (1999)Ewar et al (1999) Small sample- 18 Small sample- 18

preterm babiespreterm babies Clinical symptoms Clinical symptoms

of GORof GOR 24 hour lower 24 hour lower

oesophageal PH oesophageal PH monitoringmonitoring

PositionsPositions

Prone for 8 hoursProne for 8 hours Left lateral for 8 hoursLeft lateral for 8 hours Right lateral for 8 hoursRight lateral for 8 hours

Result – prone and left lateral Result – prone and left lateral significantly reduce GOR, decrease significantly reduce GOR, decrease in number of episodes and durationin number of episodes and duration

Case historyCase history Ex 28/40, stoma for Ex 28/40, stoma for

necnec

Full feeds, 1 kg, wt Full feeds, 1 kg, wt increasing, 28days old.increasing, 28days old.

Laid horizontal, Laid horizontal, supine, boundaries for supine, boundaries for comfortcomfort

small vomit, small vomit, increasing residuals.increasing residuals.

Chest infection. Chest infection.

Case history Case history

Term, gastroschisis, Term, gastroschisis, 3 hrly feeds, possits, 3 hrly feeds, possits, irritable fussy, nurses say he irritable fussy, nurses say he

appears hungry one hour after appears hungry one hour after feeds, more food?feeds, more food?

Case historyCase history

Term baby, meconium ileus, end to Term baby, meconium ileus, end to end anastomosisend anastomosis

Full continuous feeds Full continuous feeds Feeds changed to three hourlyFeeds changed to three hourly Loose stoolsLoose stools Vomiting, sore buttocksVomiting, sore buttocks

Put back to 2 hourly feedsPut back to 2 hourly feeds

Case historyCase history

TOF and OA, term, primary TOF and OA, term, primary anastomosisanastomosis

Full feeds, home Full feeds, home Disinterested in feedsDisinterested in feeds Pale, mucousyPale, mucousy StrictureStricture Effects on reflux episodes Effects on reflux episodes

Preterm babiesPreterm babies Poets (2004)Poets (2004) GOR common in GOR common in

preterm infants preterm infants (approx 3-5 episodes (approx 3-5 episodes per hour)per hour)

Omari et al (2002) Omari et al (2002) studied 36 infants, 14 studied 36 infants, 14 symptomatic. GORD symptomatic. GORD triggered by gastric triggered by gastric distension and distension and abdominothoracic abdominothoracic strainingstraining

Preterm babiesPreterm babies

GOR doubled with ng tube in situGOR doubled with ng tube in situ GORD is not related to delayed GORD is not related to delayed

gastric emptying so why use gastric emptying so why use prokinetic?prokinetic?

Cows milk allergy / GORCows milk allergy / GOR

CMACMA DiarrhoeaDiarrhoea Bloody stoolsBloody stools Rhinitis, nasal Rhinitis, nasal

congestioncongestion ConstipationConstipation Eczema/ dermatitisEczema/ dermatitis Lip swellingLip swelling itchingitching

Dysphagia, Dysphagia, haematemesishaematemesis

MelenaMelena Nausea, belchingNausea, belching Arching, Arching,

bradycardiabradycardia HiccupsHiccups Aspiration, chest Aspiration, chest

infectioninfection Stridor, laryngitisStridor, laryngitis

Salvatore and Vanderplas Salvatore and Vanderplas (2002)(2002)

Gastric emptying.Gastric emptying. Multiple dietary Multiple dietary

factors- volume, factors- volume, calorie density, calorie density, osmolarity, protein osmolarity, protein content all effect content all effect gastric motilitygastric motility

Type of milk regulates gastric Type of milk regulates gastric emptying rate, emptying rate,

And gastric residual contentAnd gastric residual content

Salvatore and Vanderplas (2002) Salvatore and Vanderplas (2002) reports delayed gastric emptying with reports delayed gastric emptying with GORD by causing inappropriate GORD by causing inappropriate relaxation of the lower oesophageal relaxation of the lower oesophageal sphinctersphincter

ConstipationConstipation

Formula milk associated with Formula milk associated with constipation where overfeeding constipation where overfeeding occurs.occurs.

Motility disturbanceMotility disturbance

Anti-reflux procedureAnti-reflux procedure

Sullivan (1999)Sullivan (1999) 15% - 75% neurologically impaired15% - 75% neurologically impaired Gastric dysrythmiaGastric dysrythmia Persistant activationof emetic reflexPersistant activationof emetic reflex Gastrostomy feeds are efficient and Gastrostomy feeds are efficient and

cost effectivecost effective 26% complications, GOR secondary 26% complications, GOR secondary

to PEG placement.to PEG placement.

Nissans FundoplicationNissans Fundoplication

Relieves symptoms in more than Relieves symptoms in more than 80% patients80% patients Pearl et al (1990), 234 patientsPearl et al (1990), 234 patients 153 disabled 153 disabled Post op complications 26% NI, 12% Post op complications 26% NI, 12%

othersothers Re operation 19%, 5%Re operation 19%, 5%

Fankalsrud et al (1998)Fankalsrud et al (1998)

Retrospective study 7467 patients, 7 Retrospective study 7467 patients, 7 large children hospitallarge children hospital

56% neurologically normal56% neurologically normal 44% neurologically impaired44% neurologically impaired 40% < 1 year old40% < 1 year old Good results 95% NN, 84% NIGood results 95% NN, 84% NI 4.2% complications as opposed to 4.2% complications as opposed to

12.8%12.8%

So what are we saying?So what are we saying?

Nurse baby left Nurse baby left laterallateral

Small regular feedsSmall regular feeds Observe behaviourObserve behaviour Measure and monitor Measure and monitor

residualsresiduals Crying one hour after Crying one hour after

feeds may indicate feeds may indicate GORGOR

Head tilt at risk Head tilt at risk infantsinfants

PositionPosition

The jury remains The jury remains out on many out on many aspectsaspects

Caution when Caution when critique literaturecritique literature

Treat each baby as Treat each baby as individualindividual

That is all for nowThat is all for now

Thank you for Thank you for listeninglistening

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