ASHA Reflux.ppt

  • 1,211 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
1,211
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
30
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Gastroesophageal Reflux in Infants Kathleen Borowitz, MS, CCC-SLP Speech-Language Pathologist University of Virginia Children’s Hospital
  • 2. Disclaimers
    • Speech-language pathologist, not a pediatrician
    • Married to pediatric gastroenterologist
    • Mom of a former refluxer
  • 3. Biases
    • All babies spit up
    • Reflux is over treated
    • GER is not a disease
  • 4. Gastroesophageal Reflux
    • Spontaneous regurgitation of stomach contents upward into the esophagus
  • 5. GI Tract
  • 6. Normal Physiology
    • Pharyngeal phase
      • Food moved into upper esophagus
    • Esophageal phase
      • Esophageal peristalsis actively pushing food down into the stomach
    • Gastric phase
      • Food enters stomach
      • Digestive enzymes and acid secreted and contractions begin
  • 7. Normal Physiology
    • Peristaltic waves of stomach
      • mix food w/enzymes and acid
      • Force food downward toward stomach outlet (pylorus)
      • Also forces food upward toward the LES
  • 8. Why does GER happen?
    • Lower Esophageal Sphincter
    • LES is constantly relaxed
    • LES relaxes at inappropriate time
    • Intragastric pressure increases sufficiently to overcome LES pressure
      • >50% of GER episodes
    • LES function and strength comparable in infants and adults (Hillmeier, 1996)
  • 9. Why does GER happen?
    • Modern Feeding Practices
    • Large volume feeds
    • Delayed introduction of solids
    • Prolonged recumbent periods
      • Increased use of seating devices = increased intraabdominal pressure
  • 10. Frequency of GER
    • >50% of 2 month olds spit up at least twice a day
    • More common in children with developmental disabilities
      • Symptoms more severe and persistent
  • 11. Frequency of GER
    • Various studies report findings as high as:
    • Down syndrome 75%
    • Premature birth 56%
    • Cerebral palsy 75%
    • Autism 74%
  • 12. Frequency of Infant GER adapted from Nelson et al. Arch Pediatr Adolesc Med 151:369, 1997
  • 13. When do parents consider GER a problem?
  • 14. When do parents consider GER a problem?
    • the frequency of regurgitation is more than once a day
    • the volume of regurgitation is more than 30 cc/day
    • the baby is fussy or cries excessively
    • there is discomfort with spitting up
    • frequent arching
    adapted from Nelson et al. Arch Pediatr Adolesc Med 151:369, 1997
  • 15. Infant GER
    • Begins to decrease in frequency near 6 months of age
      • Sitting, increased truncal tone
    • Further decrease in frequency near 12 months of age
      • Walking, pulling to stand
    • Typically GER completely abates by 24 months of age
  • 16. Symptoms of GER
    • Regurgitation and vomiting
    • Feeding problems
    • Pain
    • Irritability
    • Sleep disturbance
    • Respiratory difficulties
    • Growth failure
  • 17. Symptoms of GER
    • Feeding Problems
      • Dysphagia
      • Choking
      • Gagging
      • Feeding refusal
      • Fussiness/pain
  • 18. Symptoms of GER: Respiratory
    • Upper airway difficulties
    • Apnea
    • Recurrent croup
    • Recurrent or persistent laryngitis
    • Subglottic stenosis
    • Stridor
  • 19. Apnea and GER
    • “… while gastro-oesophageal reflux and obstructive episodes may co-exist . . . decreases in pH in the lower oesophagus do not usually induce either central or obstructive apnoea, and vice versa.”
    Paton et al, Eur J Pediatr 149:680, 1990
  • 20. Apnea and GER
    • “… spontaneous acid refluxes extending to the proximal portion of the oesophagus during sleep are usually not temporally related with the development of apnoeas or bradycardias.”
    Kahn et al, Eur J Pediatr 151:208, 1992
  • 21. Apnea and GER
    • Critical review of GER in preterm infants showed:
    • Apnea is unrelated to GER in most infants
    • Failure to thrive practically does not occur with GER
    • A relationship between GER and chronic airway problems has not yet been confirmed
          • Poets, Pediatr, 2004
  • 22. Specificity of Laryngoscopic Findings attributed to GER
    • 105 healthy asymptomatic adults underwent videotaped flexible laryngoscopy
      • 86% had findings attributed to reflux (many of the findings are considered pathognomonic for GERD)
      • Hicks et al. J Voice 2002;16:564
    • 120 videotaped laryngeal examinations were scored for signs of GER by 5 ENT physicians
      • poor correlation of reflux associated changes
      • poor inter-rater reliability
      • Branski et al. Laryngoscope 2002;112:1019
  • 23. Do proton pump inhibitors lessen laryngeal symptoms attributed to GER? adapted from Gatta et al. Alim Pharm Therapeut 2007:25:385-392 “ Therapy with a high-dose proton pump inhibitor is no more effective than placebo in producing symptomatic improvement or resolution of laryngo-pharyngeal symptoms.”
  • 24. Symptoms of GER: Respiratory
    • Lower airway difficulties
    • Chronic cough
    • Chronic or recurrent wheezing
    • Chronic or recurrent pneumonia
  • 25. Symptoms of GER
    • Medications for asthma may contribute to symptoms of GER
    • Decrease LES tone (methylzanthines)
    • Increase gastric acid secretion (aminophylline)
    • Cause chronic cough (ACE inhibitors, inhaled corticosteriods)
  • 26. Medical Diagnosis of GER
    • History, observation, exam
    • Barium swallow/upper GI
    • Gastroesophageal scintigraphy
    • pH probe
    • Upper GI endoscopy
  • 27. Barium Swallow
    • Videofluoroscopic study
      • Patient fed barium
      • Followed down esophagus, through LES and into stomach
    • Reflux graded 1 to 5
      • 5= reflux up into proximal esophagus w/aspiration
    • Poor sensitivity and specificity
  • 28. Radiologic Diagnosis of Childhood Gastroesophageal Reflux
    • “ The radiologic method used for showing reflux is designed to be as physiologic as possible . . . small vigorous infants are usually restrained to immobilize the arms above the head . . . the patient lies in the right lateral position, and the swallowing mechanism is briefly evaluated . . . the gastroesophageal junction is carefully examined while turning the baby gently from side to side in a supine position or occasionally rolling him 360 o .”
    taken from McCauley et al, AJR 136:47, 1978
  • 29. GE Scintigraphy
    • Patient fed technetium mixed with formula
    • Gamma camera follows the “labeled” milk through GI tract
    • Less radiation than barium swallow
    • May be useful in detecting pulmonary aspiration
    • Poor sensitivity and specificity
  • 30. pH Probe
    • Flexible pH sensor threaded down nose to esophagus to lower esophagus
    • Detects acid from stomach when refluxed into esophagus over 24 h
    • Detects frequency of episodes and length of time to clear
    • Cannot detect reflux immediately after feeding
  • 31. Endoscopy
    • Small flexible scope passed through mouth
      • Requires sedation
    • Allows direct visualization of esophageal mucosa
      • Presence/severity of esophagitis
    • Poor sensitivity
      • < ½ infants w/severe symptoms have esophagitis
  • 32. Treatment
    • Positioning
    • Dietary treatments
    • Feeding schedules
    • Medications
    • Surgery
  • 33. Treatment: Positioning
    • Feed in upright position
    • Avoid frequent or rapid changes in position during feeding
    • Avoid positions that increase intra-abdominal pressure (infant seats, swing seats)
    • Head of bed elevated
  • 34. Treatment: Thickened Feeds
    • Thickening formula or breast milk with rice cereal:
    • Decreased episodes of regurgitation
    • Decreased time crying
    • Increased time asleep
    • Reduced choking/coughing/gagging with feedings
    • Orenstein, J Pediatr 1987
  • 35. Treatment: Thickened Feeds
    • Advantages:
    • Works from the first dose
    • No pharmacologic side effects
    • Negligible cost
    • How it works:
    • Slows flow=decreases air swallowing
    • Stomach empties faster
  • 36. Treatment: Thickened Feeds
    • Recommended amount:
    • ½ teaspoon rice cereal per 30cc formula or breast milk
    • Can increase up to 1 ½ teaspoons
    • Others recommend as much as 1 tablespoon per 30cc
  • 37. Treatment: Prethickened Formulas
    • Enfamil AR
    • Substitutes approximately 30% of lactose with rice starch
    • No thicker in bottle
    • Once pH drops below 5.5 in the stomach viscosity of formula rises
  • 38. Treatment: Prethickened Formulas
    • Useful for infants with weak suck or decreased endurance
      • Cleft palate
      • Congenital heart disease
      • Prematurity
    • Does not decrease rate of flow from bottle
  • 39. Treatment: Formula Changes
    • Other than changing the character of the vomitus, formula changes are rarely associated with lasting significant symptomatic improvement
    • Incidence of GER is equivalent in breast and formula fed infants
    • There are some instances of GER due to “food allergy”
  • 40. Treatment: Feeding Techniques
    • Smaller, more frequent feeds and frequent burping during feeds
    • Less in stomach to reflux
      • May make the symptoms worse if the child cries more and swallows more air
      • Many infants with GER are difficult to burp
  • 41. Treatment: Medication
    • Antacids
      • Neutralize acid
    • H2 blockers (Zantac, Pepcid)
      • Decrease acid production
    • PPI (Previcid, Prilosec, Nexium)
      • Totally block production of acid
      • Antihistamine effect- may help if allergy component
    • Prokinetic agents (Reglan, erythromicin)
      • Make stomach empty more quickly
  • 42. Treatment: Surgery
  • 43. Treatment: Fundoplication
    • Rarely warranted in neurologically normal children
      • Severe growth failure
      • Airway obstruction
    • Postoperative complications
      • Abdominal distention/discomfort
      • Retching
      • Dumping
      • Solid dysphagia
      • Decreased swallow frequency
  • 44. SLP’s Role in Diagnosis and Treatment
    • Recognize signs/symptoms of GER during feeding
    • Recognize signs/symptoms of aspiration associated with GER
    • Consider causes of aspiration with GER
    • Give suggestions for further evaluation and non-medical management
  • 45. Aspiration
    • Episode in which a foreign substance is inhaled into the lungs
  • 46. Aspiration
    • Signs/Symptoms
    • Increased upper airway congestion
    • Strider/hoarseness
    • Apnea/bradycardia
    • Cough/gag
    • Signs of struggle during feeding
  • 47. Aspiration
    • Signs of struggle
    • Nares flared
    • Neck extension
    • Arms out
    • Head bobbing
    • Increased respiratory rate
    • Decreased O2 saturation
  • 48. AspirationAssociated with GER
    • Cricopharyngeal dysfunction
    • Vocal cord paralysis
    • Neurological disorders
    • Immature neurological system
    • Laryngeal clefts
  • 49. Laryngeal Cleft
  • 50. Aspiration: Evaluation
    • Swallow Safety
    • Cervical auscultation
    • VFSS
    • Fiberoptic endoscopic evaluation of swallow (FEES )
    • Blue dye test (trach)
  • 51. Case Study I
    • History:
    • 2 week old male, 38 weeks EGA w/duodenal atresia s/p repair on DOL 1
    • Poor PO intake, difficult to feed
  • 52. Case Study I
    • Evaluation:
    • Appearance/oral structures and oral reflexes WFL
    • NGT dependent; initiates feeds well, but quickly shows distress
      • Increased forward liquid loss
      • Pulling off nipple
      • Extension/arching/facial grimacing
      • 15-20 cc per feeding trial
  • 53. Case Study I
    • Impression:
    • Experiencing esophageal dysmotility and/or GER while feeding
      • UGI study confirmed significant GER
    • Recommended :
    • d/c PPI and initiate trial of Enfamil AR for all feeds
  • 54. Case Study I
    • Result:
    • Began taking 60-70 cc per feed with sustained, rhythmical suck
    • No signs of distress/discomfort during feeds
    • Continued occasional small reflux episodes
  • 55. Case Study II
    • History
    • 3 month old former 25 week premie, H/O intubation, RDS and GER
    • Home from NICU 2 weeks on Enfamil AR
    • Readmitted due to “blue spells and slowed breathing” during feeding
  • 56. Case Study II
    • Evaluation
    • Proptosis and wide, blunted tongue
    • Mildly hoarse voice and stridor
    • Intact oral reflexes w/vigorous suck
    • Very rapid intake w/frequent decreases in O2 saturations and heart rate and pulling off nipple for catch-up breathing
  • 57. Case Study II
    • Impression
    • Voracious feeder w/poor ability to coordinate suck-swallow-breathe
    • Signs/symptoms of reflux both during and after feeds
    • AR may have helped somewhat with GER but not with suck-swallow coordination or possible air swallowing
  • 58. Case Study II
    • Recommended
    • d/c AR and trying regular formula thickened with rice cereal
    • Fully upright positioning during feeding
  • 59. Case Study II
    • Result
    • Sustained suck with no signs of distress or pulling off nipple
    • Calmer state
    • Able to maintain O2, HR and RR through full feeding
  • 60. Summary
    • GER is very common in infants
    • Most children outgrow reflux by 24 months
    • Serious complications of GER are rare
    • The role of GER in the etiology of apnea, asthma and upper airway symptoms is unclear
  • 61. Summary
    • Try simple treatments for GER first
    • Infants with normal anatomy and intact neurological systems protect their airway
    • SLPs can recognize signs and symptoms of GER and aspiration associated with GER during feeding
  • 62. Kathleen Borowitz, MS, CCC-SLP University of Virginia Health System Therapy Services 434.924.8245 [email_address]