GASTRO-OESOPHAGEAL REFLUX

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GASTRO-OESOPHAGEAL REFLUX

• ANNE ASPIN
• 2010

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Douglas (2005)

• Excessive crying
• 30 of infants to GP
• Increase GOR in babies who cry excessively
• Parents believe they have reflux

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• Key factors that impact on infant distress
• Feeding management
• Parental responsiveness
• Sensory nourishment
• Sleep management

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Feeding management

• Frequent feeding
• Breast or bottle feeding technique
• Cows milk allergy

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Parent responsiveness

• Response depends upon urgency of cry
• Louder , high pitch scream communication
• Need prompt response to cues

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Sensory nourishment

• Sling / harness
• Walks
• Massage
• Bathing
• Soft music

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Sleep management

• Sleep routine, night, day, quiet time
• 18.00hrs most increased reflux rythmn
• Dreizzan et al (1990)

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Effects of these responses

• Decreased crying at less than 3-4 mths of age
• Decreased incidence of GORD once they are older.

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Health promotion

• Shenassa et al (2004)
• Early prevention and health promotion in maternal
  smoking and infantile gastro intestinal
  dysregulation

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motilin

• An amino acid hormone produced by the duodenum
  and jejunum mucosa
• Released every 90 minutes when fasting
• Vagal nerve stimulation increases the number and
  force of contraction
• Difficulty with comforting a crying baby may be
  due to cycle of increased gut motility, continual
  crying and higher motilin levels

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Purpose of study

• Infants exposed to cigarette smoke is linked to
  elevated blood motilin levels
• Which is linked to increased risk of
  gastro-intestinal dysregulation including colic
  and acid reflux

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Method

• Critical review
• Epidemiology, Physiologic, Biological evidence
  
• Smoking and colic
• Smoking and motilin levels
• Motilin and colic

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Results

• Six studies
• Results from five studies shows there is an
  association with maternal smoking and excessive
  crying and intestinal colic
• Smoking is linked to increased plasma and
  intestinal motilin levels
• Higher than average level of motilin are linked
  to increased colic

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A case for left lateral positioning

• Tobin et al (1997)
• Prone posture recommended for GOR but associated
  with SID

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STUDY

• 24 infants gt 4days, lt5/12 with symptoms GOR
  studies 48hrs PH
• Randomly assigned prone, supine, left or right
  lateral
• 1st 24hrs horizontal then 30o head elevation

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Results

• GOR significantly less in prone and left lateral
  position than supine and right lateral position
• Conclusion for this study, elevation may not
  always be of value

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Carre (1960), Meyers et al (1982)

• I would disagree.
• Car seats, elevation of the head of the cot.
• Risk of slumping- cause raised intra abdominal
  pressure and reflux
• (Dodds et al 1981, Orenstein et al 1983, Jolley
  et al 1978

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Back to the drawing board

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

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Method

• 12 spontaneous breathing preterm infants with
  idiopathic recurrent apnoea studied in a
  randomized controlled crossover trial.
• 24 hrs prone and horizontal
• 24 hrs prone 15 degree tilt
• Position changed 6 hourly randomly

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Result

• Improved gastric emptying
• Improved weight gain
• Faster gastric emptying on tilt
• No difference in gastric residuals
• Some studies show increased apnoea with GOR,
  whereas others do not

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Are we seeing the light?

• Ewar et al (1999)
• Small sample- 18 preterm babies
• Clinical symptoms of GOR
• 24 hour lower oesophageal PH monitoring

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Positions

• Prone for 8 hours
• Left lateral for 8 hours
• Right lateral for 8 hours
• Result prone and left lateral significantly
  reduce GOR, decrease in number of episodes and
  duration

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Case history

• Ex 28/40, stoma for nec
• Full feeds, 1 kg, wt increasing, 28days old.
• Laid horizontal, supine, boundaries for
  comfort
• small vomit, increasing residuals.
• Chest infection.

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Case history

• Term, gastroschisis,
• 3 hrly feeds, possits,
• irritable fussy, nurses say he appears hungry one
  hour after feeds, more food?

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Case history

• Term baby, meconium ileus, end to end anastomosis
• Full continuous feeds
• Feeds changed to three hourly
• Loose stools
• Vomiting, sore buttocks
• Put back to 2 hourly feeds

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Case history

• TOF and OA, term, primary anastomosis
• Full feeds, home
• Disinterested in feeds
• Pale, mucousy
• Stricture
• Effects on reflux episodes

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Preterm babies

• Poets (2004)
• GOR common in preterm infants (approx 3-5
  episodes per hour)
• Omari et al (2002) studied 36 infants, 14
  symptomatic. GORD triggered by gastric distension
  and abdominothoracic straining

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Preterm babies

• GOR doubled with ng tube in situ
• GORD is not related to delayed gastric emptying
  so why use prokinetic?

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Cows milk allergy / GOR

• CMA
• Diarrhoea
• Bloody stools
• Rhinitis, nasal congestion
• Constipation
• Eczema/ dermatitis
• Lip swelling
• itching

• Dysphagia, haematemesis
• Melena
• Nausea, belching
• Arching, bradycardia
• Hiccups
• Aspiration, chest infection
• Stridor, laryngitis

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Salvatore and Vanderplas (2002)

• Gastric emptying.
• Multiple dietary factors- volume, calorie
  density, osmolarity, protein content all effect
  gastric motility

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• Type of milk regulates gastric emptying rate,
• And gastric residual content
• Salvatore and Vanderplas (2002) reports delayed
  gastric emptying with GORD by causing
  inappropriate relaxation of the lower oesophageal
  sphincter

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Constipation

• Formula milk associated with constipation where
  overfeeding occurs.
• Motility disturbance

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Anti-reflux procedure

• Sullivan (1999)
• 15 - 75 neurologically impaired
• Gastric dysrythmia
• Persistant activationof emetic reflex
• Gastrostomy feeds are efficient and cost
  effective
• 26 complications, GOR secondary to PEG placement.

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Nissans Fundoplication

• Relieves symptoms in more than 80 patients
• Pearl et al (1990), 234 patients
• 153 disabled
• Post op complications 26 NI, 12 others
• Re operation 19, 5

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Fankalsrud et al (1998)

• Retrospective study 7467 patients, 7 large
  children hospital
• 56 neurologically normal
• 44 neurologically impaired
• 40 lt 1 year old
• Good results 95 NN, 84 NI
• 4.2 complications as opposed to 12.8

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So what are we saying?

• Nurse baby left lateral
• Small regular feeds
• Observe behaviour
• Measure and monitor residuals
• Crying one hour after feeds may indicate GOR
• Head tilt at risk infants

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Position

• The jury remains out on many aspects
• Caution when critique literature
• Treat each baby as individual

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That is all for now

• Thank you for listening

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References

• Douglas P (2005). Excessive Crying and
  Gastro-Oesophageal Reflux Disease in Infants
  Misalignment of Biology and Culture. Medical
  Hypotheses. Vol 64, Issue 5, Pg 887-898
• Ewer A, James M, Tobin J (1999). Prone and Left
  lateral Positioning Reduce Gastro-Oesophageal
  Reflux in Preterm Infants. Archives of Disease in
  Childhood. 81 F201 - F205
• Fonkalsrud E, Ashcraft K, Coran A, Ellis D,
  Grosfield J, Tunell W, Weber T (1998). Surgical
  Treatment of Gastroesophageal Reflux in Children
  
• A Combined Hospital Study of 7467 Patients.
  Paediatrics. Vol 101, No. 3
• Huang R-C, Forbes DA, Davies MW (2005). Feed
  Thickener for Newborn Infants with
  Gastro-Oesophageal Reflux (Review). The Cochrane
  Collaboration. Issue 2

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References cont.

• Jenni O, Siebenthal K, Wolf M, Keel M, Duc G and
  Bucher H (1997). Effect of Nursing in the head
  Elevated Tilt Positon (15º) on the Incidence of
  Bradycardic and Hypoxemic Episodes in Preterm
  Infants. Paediatrics. 100 622-625
• Nelson S, Chen E, Syniar G, Kaufer Christoffel K
  (1998). One-Year Follow-up of Symptoms of
  Gastroesophageal Reflux During Infancy.
  Paediatrics. 10267
• Omarj T, Barnett C, Benninga M, Lontis R,
  Goodchild L, Haslam R,
• Dent J, Davidson G. Mechanisms of
  Gastro-oesophageal Reflux in Preterm and Term
  Infants with Reflux Disease. Gut51 475-479
• Peter C, Sprodowski N, Bohnhorst B, Silny J,
  Poets C (2002). Gastroesophageal Reflux and Apnea
  of Prematurity No Temporal Relationship.
  Paediatrics. 109 8 - 11
• Philips B (Ed) (2002). Towards Evidence Based
  Medicine for Paediatricians.
• Archives of Disease in Childhood. B677-81
• Poets C (2004). Gastroesophageal Reflux A
  Critical Review of Its Role In Preterm Infants.
  Paediatrics. 113 128-132

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References cont.

• Salvatore S, Vandenplas Y (2002).
  Gastroesophageal Reflux and Cow Milk Allergy Is
  There a Link? Paediatrics. Vol. 110
• Shenassa E, Brown M. Maternal Smoking and
  Infantile Gastrointestinal Dysregulation The
  Case of Colic. Paediatrics. Vol. 114 No. 4
  October 2004
• Sullivan P (1999). Gastrostomy feeding in the
  disabled child when is an anti-reflux procedure
  required? Archives of Disease in Childhood. 81
  463-464
• Tighe M and Beattie R (2010). Managing
  gastro-oesophageal reflux in infancy. Archives of
  Disease in Childhood. 95 243 - 244
• Tobin J, McCloud P, Cameron D (1997). Posture and
  Gastro-oesophageal Reflux A Case for Left
  Lateral Positioning. Archives of Disease in
  Childhood. 76 254-258
• Wenzi T, Schneider S, Scheele F, Silny J, Heimann
  G, Skopnik H (2003). Effects of Thickened Feeding
  on Gastroesophageal Reflux in Infants A
  Placebo-Controlled Crossover Study Using
  Intraluminal Impedance. Paediatrics. 111 355 -
  359