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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

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douglas 2005
Douglas (2005)
  • Excessive crying
  • 30% of infants to GP
  • Increase GOR in babies who cry excessively
  • Parents believe they have reflux
slide3
Key factors that impact on infant distress
  • Feeding management
  • Parental responsiveness
  • Sensory nourishment
  • Sleep management
feeding management
Feeding management
  • Frequent feeding
  • Breast or bottle feeding technique
  • Cows milk allergy
parent responsiveness
Parent responsiveness
  • Response depends upon urgency of cry
  • Louder , high pitch scream – communication
  • Need prompt response to cues
sensory nourishment
Sensory nourishment
  • Sling / harness
  • Walks
  • Massage
  • Bathing
  • Soft music
sleep management
Sleep management
  • Sleep routine, night, day, quiet time
  • 18.00hrs most increased reflux rythmn

Dreizzan et al (1990)

effects of these responses
Effects of these responses
  • Decreased crying at less than 3-4 mths of age
  • Decreased incidence of GORD once they are older.
health promotion
Health promotion
  • Shenassa et al (2004)
  • Early prevention and health promotion in maternal smoking and infantile gastro intestinal dysregulation
motilin
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
Purpose of study
  • Infants exposed to cigarette smoke is linked to elevated blood motilin levels
  • Which is linked to increased risk of gastro-intestinal dysregulation including colic and acid reflux
method
Method
  • Critical review
  • Epidemiology, Physiologic, Biological evidence
  • Smoking and colic
  • Smoking and motilin levels
  • Motilin and colic
results
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
A case for left lateral positioning
  • Tobin et al (1997)
  • Prone posture recommended for GOR but associated with SID
study
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
results16
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
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
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)
method19
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
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
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
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
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 history24
Case history
  • Term, gastroschisis,
  • 3 hrly feeds, possits,
  • irritable fussy, nurses say he appears hungry one hour after feeds, more food?
case history25
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 history26
Case history
  • TOF and OA, term, primary anastomosis
  • Full feeds, home
  • Disinterested in feeds
  • Pale, mucousy
  • Stricture
  • Effects on reflux episodes
preterm babies
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 babies28
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

Cows milk allergy / GOR
salvatore and vanderplas 2002
Salvatore and Vanderplas (2002)
  • Gastric emptying.
  • Multiple dietary factors- volume, calorie density, osmolarity, protein content all effect gastric motility
slide31
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
Constipation
  • Formula milk associated with constipation where overfeeding occurs.
  • Motility disturbance
anti reflux procedure
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
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
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
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
Position
  • The jury remains out on many aspects
  • Caution when critique literature
  • Treat each baby as individual
that is all for now
That is all for now

Thank you for listening

references
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 inChildhood. 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
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 Follow-up 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 cont41
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 anti-reflux 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
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