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GastroesophagealReflux in Infants and Children
Swallowing reflex begins at 16 weeks gestation
Can suckle by 2nd to 3rd trimester
34 weeks, infant can suckle and feed normally
Pharyngeal phase earlier developed
Oral preparatory phase maldeveloped in premature infants
DefinitionsGER Involuntary passage of gastric contents
into esophagus
GERD Symptoms or complications that may occur when gastric contents reflux into esophagus or oropharynx
Regurgitation Passage of refluxed gastric contents into oral pharynx
Vomiting Expulsion of refluxed gastric contents from mouth
What is Gastroesophageal Reflux Disease?
When highly acidic contents of the stomach are refluxed back up to the esophagus These gastric contents irritate and sometimes
damage mucosal surfaces of the esophagus It is a clinical condition that is severe enough
to impact the patient’s life and/or damage the esophagus
Gastroesophageal Reflux in Infants
An infant will throw up after almost every feeding and many times between feedings.
This is usually due to an incoordination or immaturity of the upper respiratory tract.
Parents often worry that something more is wrong with the baby’s stomach Ulcer Not keeping enough food down to grow
The Antireflux Barrier
Transient LES Relaxations
Tracings reprinted from Kawahara et al, Gastroenterology 1997;113:399
Esophagus
LES
Cruraldiaphragm
Pylorus
Stomach
Angle of His
Pharynx
UES
Esophageal Capacitance
• Shorter esophagus• Smaller capacity
Gravity
Adult
Infant
Airway Protective Mechanisms
ESOPHAGEAL DISTENTION UES contracts
Vagal reflexesVocal cords closeCentral apnea occursUES relaxes
0.15 s
Refluxate enters pharynx0.3 s
Swallowing clears pharynx0.6 s
Small volume
1.0 sRespiration resumes
Large volume
Pathogenic Factors in GERD Mechanisms of GER• Transient LES relaxation• Intra-abdominal pressure• Reduced esophageal capacitance• Gastric compliance• Delayed gastric emptying
Mechanisms of Esophageal Complications• Impaired esophageal clearance• Defective tissue resistance• Noxious composition of refluxate
Mechanisms of Airway Complications• Vagal reflexes• Impaired airway protection
Esophagus
LES
Cruraldiaphragm
Pylorus
Stomach
Angle of His
Pharynx
UES
Common Symptoms
It is unknown whether adults and infants have the same symptoms
Infants are most likely to have: Frequent or recurrent vomiting Heartburn Gas Abdominal pain
Diagnosis
Usually hearing the parents story and seeing the child is enough to determine this problem
A few diagnostic tests that are given when further testing is recommended Barium Swallow or Upper GI series pH Probe Endoscopy
Barium Swallow
X-ray allowing doctors to follow food down the infants esophagus into the intestines
Doctor is able to see if there are twists, kinks, or a narrowing of the upper intestinal tract
Not very reliable
pH Probe
Performed by the use of a small wire with an acid sensor
Starts at the infants nose and ends at the bottom of the esophagus
Sensor is left in place for 12-24 hours The severity of the reflux does not always
correlate with the severity of the symptoms
Esophageal pH Monitoring
•Cannot detect nonacidic reflux
•Cannot detect GER complications associated with “normal” range of GER
•Not useful in detecting association between GER and apnea unless
combined with other techniques
Limitations
•Detects episodes of reflux
•Determines temporal association between acid GER and symptoms
•Determines effectiveness of esophageal clearance mechanisms
•Assesses adequacy of H2RA or PPI dosage in unresponsive patients
Advantages
Endoscopy
A flexible endoscope with lights and lenses are passed through the infants mouth.
Esophagitis Due to repeated exposure of the esophagus to
stomach acid
Less than half of the infants with severe symptoms do not develop esophagitis
Esophagogastroduodenoscopy (EGD)
•Need for sedation or anesthesia
•Endoscopic grading systems not yet validated for pediatrics
•Poor correlation between endoscopic appearance and histopathology
•Generally not useful for extra- esophageal GERD
Limitations
•Enables visualization and biopsy of esophageal epithelium
•Determines presence of esophagitis, other complications
•Discriminates between reflux and non- reflux esophagitis
Advantages
Treatment
Positioning the baby After feeding, put the baby on his stomach, and
elevate the head Changing feeding schedules
Feed baby smaller amounts more often Dietary treatments
Parents are instructed to thicken their infants formula with cereal
Treatment Continued
Medications are used: Lessen intestinal gas Decrease or neutralize
stomach acid Improve intestinal
coordination
Surgery Extremely rare Nissen Fundoplication
Mechanisms of Respiratory Responses to GER
Principles of Antireflux Surgery
Restore intra-abdominal segment
of esophagus
Approximatediaphagmatic
crurae
Reduce hiatal herniawhen present
Wrap fundus around LES to reinforce antireflux barrier
Epiglottic Flap Closure
Glottic Closure
Tracheoesophageal Diversion and Laryngotracheal Separation