ASHA Reflux.ppt
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ASHA Reflux.ppt Presentation 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]