Watch for gastroesophageal reflux(GER), which can cause serious problems if untreated
Watch for gastroesophageal reflux(GER), which can cause serious problems if untreated: Excerpt from Avoiding Common Pediatric Errors
Author:
Ellen Hamburger, MD
What to Do - Interpret the Data
The presentation of GER can be varied, subtle, and differ considerably
dependinguponthechild'sage.GERiscausedbytransientloweresophageal
sphincterrelaxation,whichallowspassiveflowofacidicandnonacidicgastric
contents into the esophagus.
In infancy, reflux is likely to develop at approximately 1 month of age.
Preterm infants may develop the condition even earlier. The incompetence
of the lower esophageal sphincter allows the increasing volumes of breast
milk or formula to wash up the esophagus, resulting in spitting up or frank
vomiting. In addition to a motility disorder, there is now good evidence that
food hypersensitivity is a cause of some cases of infant reflux. More severe
symptoms occur in babies who reflux and swallow stomach contents, rather
thanspit uporvomit. These infants develop esophagitis fromacidicstomach
contents washing up and down the esophagus. Their clinical presentation
is one primarily of arching and crying. In addition, they often have nasal
congestion, frequent hiccups, and, less frequently, a cough. Parents often interpretthediscomfortas"gas."Inprimarycaresettings,cliniciansshouldask
aboutrefluxsymptomsatthe1monthwell-childvisit,becauseparents rarely
recognize the fussiness associated with esophagitis as a symptom of reflux.
If the reflux progresses, untreated, feedings can be disrupted. After
beginning to feed, babies pop off the nipple (breast or bottle) to arch and cry.
Ultimately, feeding aversion and failure to thrive can result. Parents often
report that the only time the babies will feed is when they are almost asleep.
The more relaxed state seems to have a protective effect on the amount
of refluxing. There is no clear association between apnea or apparent life-
threatening events (ALTE) and reflux.
In older children, reflux can present with more classic symptoms of
"heartburn" with chest pain and discomfort. Pulmonary symptoms, including recurrent pneumonia, exacerbation of asthma, or chronic cough can also
develop. The interplay between asthma and reflux can be confusing. Cases
of refractory asthma may warrant diagnostic evaluation for reflux or a diagnostic trial of acid-suppressant therapy.
In infants, the diagnosis is made primarily by history. If weight gain is
appropriate, further workup is often not necessary. For infants with accompanying symptoms of feeding difficulties or failure to thrive, diagnosis can
often be achieved with a good history and a therapeutic trial as described
below. When response to treatment is not adequate, further studies may be
necessary to ensure correct diagnosis.
Thereisvariabilityintheuseofvariousdiagnosticstudiesandarechosen
in part based on symptoms. A barium swallow is advisable for infants refractory to treatment who have pulmonary symptoms such as cough, wheeze, or
stridor. A barium swallow may demonstrate anatomic malformations such as
a tracheoesophageal fistula, intestinal malrotation, or a vascular ring whose
symptoms mimic reflux. In older children, it can demonstrate hiatal hernia
and esophageal stricture. Children with dysphagia or odynophagia (painful
swallowing) should also have a barium esophagram.
Esophageal pH monitoring is another valid and reliable measure of acid
reflux. It can help in establishing the temporal association of symptoms and
acid reflux as well as the adequacy of acid-suppressant therapy. For infants
andchildrenwhoserefluxisinlargepartnonacidic,itisnothelpful.Thismay
be particularly true for many asthma patients whose course is complicated
by reflux. Finally, endoscopy and biopsy are useful to assess the presence and
severityofesophagitis,strictures,andBarrettesophagusandtoexcludeother
disorders such as eosinophilic or infectious esophagitis. It may be warranted
in refractory asthmatics as well.
The initial treatment for infants includes conservative measures designed to keep the milk in the stomach; thickening feeds and the use of gravity. Feeding should be thickened with baby cereal (rice or oatmeal) starting
with 1 teaspoon per ounce and increasing to as high as 3 teaspoons per ounce.
Alternatively, there are commercial formula options that thicken on contact
with stomach acid. Given the association of GER with food hypersensitivity, a trial of elimination of milk and soy from a breastfeeding mother's diet
or feeding amino acid-based formula is worthwhile. Positioning should be
either vertical in the caretaker's arms or lying supine on a surface placed at
almost a 45-degree incline.
For older children and adolescents, conservative measures and lifestyle
changes can provide relief. Positioning during sleep with the head elevated
and lying on the left side can be beneficial. Further, these patients should
avoid foods that exacerbate symptoms including caffeine, chocolate, alcohol,
and spicy foods. Obesity and exposure to tobacco also have adverse effects
on reflux.
In infants, if there are clearly signs of esophagitis (arching, crying, with
or without excessive hiccups, nasal congestion), acid-suppressant therapy
should be started before a feeding aversion develops. Older children with
heartburn should also receive acid-suppressants. For infants and older children,proton pump inhibitorsappear to be moreeffective inacid suppression
and healing esophagitis than H2 blockers. Prokinetic agents have not proven
useful. Surgical therapy for reflux is fundoplication. There are no good clinical trials comparing surgery to aggressive medical management comparing
potential risks, benefits, and costs.
Suggested Readings
Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy.
Curr Opin Allergy Clin Immunol. 2006;6(3):220–225.
Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux
during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch
Pediatr Adolesc Med. 1997;151:569–572.
Rudolph CD, Mazur LJ, Liptak GS, et al. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux
in infants and children: recommendations of the North American Society for Pediatric
Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(Suppl 2):S1–S31.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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