Transcript GASTRO-OESOPHAGEAL REFLUX

GASTRO-OESOPHAGEAL
REFLUX
ANNE ASPIN
2010
Douglas (2005)




Excessive crying
30% of infants to GP
Increase GOR in babies
who cry excessively
Parents believe they have
reflux
Key factors that impact on infant distress
 Feeding management
 Parental responsiveness
 Sensory nourishment
 Sleep management
Feeding management



Frequent feeding
Breast or bottle feeding technique
Cows milk allergy
Parent responsiveness



Response depends upon urgency of cry
Louder , high pitch scream – communication
Need prompt response to cues
Sensory nourishment





Sling / harness
Walks
Massage
Bathing
Soft music
Sleep management


Sleep routine, night, day, quiet time
18.00hrs most increased reflux rythmn
Dreizzan et al (1990)
Effects of these responses

Decreased crying at less than 3-4 mths of age

Decreased incidence of GORD once they are
older.
Health promotion

Shenassa et al (2004)

Early prevention and
health promotion in
maternal smoking and
infantile gastro intestinal
dysregulation
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
Purpose of study

Infants exposed to cigarette smoke is linked to
elevated blood motilin levels

Which is linked to increased risk of gastrointestinal dysregulation including colic and acid
reflux
Method

1.
2.
3.
Critical review
Epidemiology, Physiologic, Biological evidence
Smoking and colic
Smoking and motilin levels
Motilin and colic
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
A case for left lateral positioning

Tobin et al (1997)

Prone posture
recommended for GOR
but associated with SID
STUDY



24 infants > 4days,
<5/12 with symptoms
GOR studies 48hrs PH
Randomly assigned
prone, supine, left or
right lateral
1st 24hrs horizontal then
30o head elevation
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
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
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)
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


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
Are we seeing the light?




Ewar et al (1999)
Small sample- 18
preterm babies
Clinical symptoms of
GOR
24 hour lower
oesophageal PH
monitoring
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
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.
Case history



Term, gastroschisis,
3 hrly feeds, possits,
irritable fussy, nurses say he appears hungry one
hour after feeds, more food?
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




Case history






TOF and OA, term, primary anastomosis
Full feeds, home
Disinterested in feeds
Pale, mucousy
Stricture
Effects on reflux episodes
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
Preterm babies


GOR doubled with ng tube in situ
GORD is not related to delayed gastric
emptying so why use prokinetic?
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
Salvatore and Vanderplas (2002)


Gastric emptying.
Multiple dietary factorsvolume, calorie density,
osmolarity, protein
content all effect gastric
motility



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
Constipation


Formula milk associated with constipation
where overfeeding occurs.
Motility disturbance
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.
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%

Fankalsrud et al (1998)






Retrospective study 7467 patients, 7 large
children hospital
56% neurologically normal
44% neurologically impaired
40% < 1 year old
Good results 95% NN, 84% NI
4.2% complications as opposed to 12.8%
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
Position



The jury remains out on
many aspects
Caution when critique
literature
Treat each baby as
individual
That is all for now
Thank you for listening
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
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 Followup of Symptoms of Gastroesophageal Reflux During Infancy. Paediatrics.
102:67
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. Gut:51 ; 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. B6:77-81
Poets C (2004). Gastroesophageal Reflux: A Critical Review of Its Role In
Preterm Infants. Paediatrics. 113 : 128-132
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 antireflux 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