ASHA Reflux.ppt


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ASHA Reflux.ppt

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