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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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Gastro oesophageal reflux l.jpg

GASTRO-OESOPHAGEAL REFLUX

ANNE ASPIN

2010


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Douglas (2005)

  • Excessive crying

  • 30% of infants to GP

  • Increase GOR in babies who cry excessively

  • Parents believe they have reflux


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Key factors that impact on infant distress

  • Feeding management

  • Parental responsiveness

  • Sensory nourishment

  • Sleep management


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Feeding management

  • Frequent feeding

  • Breast or bottle feeding technique

  • Cows milk allergy


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Parent responsiveness

  • Response depends upon urgency of cry

  • Louder , high pitch scream – communication

  • Need prompt response to cues


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Sensory nourishment

  • Sling / harness

  • Walks

  • Massage

  • Bathing

  • Soft music


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Sleep management

  • Sleep routine, night, day, quiet time

  • 18.00hrs most increased reflux rythmn

    Dreizzan et al (1990)


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Effects of these responses

  • Decreased crying at less than 3-4 mths of age

  • Decreased incidence of GORD once they are older.


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Health promotion

  • Shenassa et al (2004)

  • Early prevention and health promotion in maternal smoking and infantile gastro intestinal dysregulation


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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


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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


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Method

  • Critical review

  • Epidemiology, Physiologic, Biological evidence

  • Smoking and colic

  • Smoking and motilin levels

  • Motilin and colic


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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


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A case for left lateral positioning

  • Tobin et al (1997)

  • Prone posture recommended for GOR but associated with SID


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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


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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


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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


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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)


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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


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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


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Are we seeing the light?

  • Ewar et al (1999)

  • Small sample- 18 preterm babies

  • Clinical symptoms of GOR

  • 24 hour lower oesophageal PH monitoring


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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


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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.


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Case history

  • Term, gastroschisis,

  • 3 hrly feeds, possits,

  • irritable fussy, nurses say he appears hungry one hour after feeds, more food?


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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


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Case history

  • TOF and OA, term, primary anastomosis

  • Full feeds, home

  • Disinterested in feeds

  • Pale, mucousy

  • Stricture

  • Effects on reflux episodes


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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


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Preterm babies

  • GOR doubled with ng tube in situ

  • GORD is not related to delayed gastric emptying so why use prokinetic?


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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


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Salvatore and Vanderplas (2002)

  • Gastric emptying.

  • Multiple dietary factors- volume, calorie density, osmolarity, protein content all effect gastric motility


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Constipation

  • Formula milk associated with constipation where overfeeding occurs.

  • Motility disturbance


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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.


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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%


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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%


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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


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Position

  • The jury remains out on many aspects

  • Caution when critique literature

  • Treat each baby as individual


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That is all for now

Thank you for listening


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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


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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


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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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