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Understanding and Managing

Reflux/GERD in

Typically Developing Babies

And Older Children with Medical Complexities

A Discussion for Caregivers and

Healthcare Professionals

Developmental and Physiological Considerations,

Therapeutic Approaches, and Recommendations

by Mary B. Pengelley, PT, DPT, ATP

Provider Disclaimer

• Allied Health Education and the presenter of

this webinar do not have any financial or other

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that may be discussed or displayed in this

presentation.

• There was no commercial support for this

presentation.

• The views expressed in this presentation are

the views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

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Background and Introductions

Peace Corps Jamaica

Charter School

Pediatric Private Practice

Community Service

Reminders Before We Start

This webinar is aimed at improving understanding, critical thinking and clinical judgment when working with children with reflux

The information presented in this webinar is based on personal and clinical experiences, extensive review of current research, and some ‘gems’ gained from continuing education and graduate school

Please use your own best reasoning and clinical judgment when working with children and making suggestions to families

Refer to appropriate specialists as needed for concerns outside your scope of practice or professional judgment

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Objectives1. Definitions: What’s the Difference?

a. GER

b. GERD

2. Causes: Getting the Big Picture

a. Typical Infant Anatomy and Physiology

b. Normal Changes to Expect with Development

c. Norms of Various Cultural Practices

d. Perinatal and long term medical complications

3. Consequences: So What?

a. Developmental Delays/Torticollis

b. Sensory Defensiveness/Picky Eaters

c. Poor Weight Gain/Failure to Thrive

4. Treatment Tricks and Techniques: There’s Help! a. Non-pharmaceutical – diet, volume, positioning, strengthening

b. Pharmaceutical

c. Surgical

Definitions: GER1,2 - “Happy Spitters”

Uncomplicated Gastroesophageal Reflux (GER)1

GER: the passage of gastric contents into the esophagus with or without regurgitation and vomiting.

50% of normal full term infants, 0-3 months spit up 1x/day or more

Most common concern at 4-month well-baby check-up

Baby feeds well

Normal weight gain

No unusual irritability

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Definitions: Gastroesophageal Reflux Disease/GERD1,2

GERD: when GER leads to troublesome symptoms that affect daily functioning and/or results in complications

Refractory GERD: GERD, not responding to optimal treatment after 8 weeks

10% of Full-term Infants

Esophageal – ‘silent reflux’

Extraesophageal

Reflux with Pathological Consequences

Esophagitis/Pain

Nutritional compromise/Poor Weight Gain

Respiratory Complications

Normal vs. Red Flags

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What do RED FLAGS mean?Time to refer out!

General

•Weight Loss•Lethargy•Fever•Excessive Irrritablity/pain

•Dysuria•Onset > 6 months or increasing/persisting > 12-18 months

•May be due to systemic infections, UTI, otitis media, or diagnosis other than GERD

Neurological

•Bulging fonatanels•Rapidly increasing head circumference

•Seizures•Micro or Macro-cephaly

•Subdural hematoma•Intracranial hemorrhage

•May be due to raised intracranial pressure, meningitis, brain tumor or hydrocephalus, shaken baby syndrome

Gastrointestinal

•Persistent Forceful vomiting

•Nocturnal vomiting•Bilious vomiting•Blood in vomit•Rectal bleeding•Chronic diarrhea •Abdominal distension

•Many possible causes: anatomic abnormalities such as pyloric stenosis, intestinal obstruction, GI bleeding, food allergy, gastroenteritis, dysmotility, gastroparesis, appendicitis, pancreatitis

Cardiopulmonary

•Decreased O2 satswhile feeding (cyanosis)

•Poor feeding/sucking•Fatigues quickly while feeding

•Shortness of breath•General lethargy

•May be related to congenital heart disease, cardiac failure, broncopulmonarydysplasia, pneumonia, upper airway infections, restrictive airway disease (asthma)

Metabolic/Toxic

•Normal at birth, develops anorexia within weeks of birth

•Excessive vomiting in newborn

•Convulsions•Jaundice •Hyper or Hypo-ventilation

•Poor thermoregulation

•Galactosemia, hereditary fructose intolerance, metabolic acidosis, urea cycle defects, amino acidemia, congenital adrenal hyperplasia

American Academy

of Pediatrics

Differential

Diagnosis of

GER/GERD 2,3

Recognize Red Flags

Understand complicated GERD

Caregiver Education for Happy Spitters

If not resolved by 18 months consult with GI

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Non Pharmacological Treatment Options to Reduce Signs and Symptoms of GER/GERD

•Rice Cereal (with low or no arsenic)•Breast milk Carob Bean (> 42 wks gestation) or Xanthum Gum (> 1yr)

Thicken Feeding

•Avoid Overfeeding•Feeding more frequently while decreasing volume per feed

•Total Daily Amount maintained

Reduce Volume

•Encourage exclusive breast feeding•Maternal restriction of dairy > 2 wks•Formula feeding try extensively hydrolyzed formula or free amino-acid based formula > 2 wks

Eliminate Cow’s Milk

Protein

•Back to Sleep/Safe to Sleep for all infants•Left lateral sidelying older children•Elevate head on wedge during feeding or hold upright after feeding

Position

•Probiotics - not well studied, costly•Weight loss with obesity – older children•Massage – decrease infant cortisol levels•Rocking/holding – bidirectional benefits

Other

2018 North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN, ESPGHAN)

NASPGHAN 2018 Recommendations

2018 guidelines differ from 2009 guidelines:

1. Focus on reducing acid suppression whenever possible with short empiric trials of 4 to 8 weeks recommended for GERD symptoms

2. Shift away from attributing respiratory and laryngeal symptoms to GER

3. Add algorithm for typical symptoms to incorporate reflux testing to differentiate patients with reflux based diagnoses versus functional diagnoses

4. Add recommendation for change of formula to a protein hydrolysate or amino acid based formula before acid suppression in infants.

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Understanding the Big Picture in Typical Development

Review

Infant

A & P

Changes with Development

Impact of Cultural Practices

Normal ‘Spit-up’ or Reflux? When is it a problem?

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Typical Infant Anatomy and Physiology

Understanding Development of the Infant Respiratory and GI Systems

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Musculo-Skeletal

Newborn Anatomy

and Physiology:

1.Triangular shaped chest

Ribs horizontal &

cartilaginous

1.Diaphragmatic nose

breather &

pulmonary reserve

Thin intercostal

spacing & sternal

stability

1.Demands paradoxical breathing

1.Soft trachea, high Respiratory Rate, low Tidal

Volume

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• Visible sternal retraction due to soft cartilaginous ribs and sternum

• Strong abdominal contractions

• Crying helps develop abdominal strength and stretch out the intercostals for deeper breathing

3-6 Months What Happens in Normal Development

Baby begins reaching with UE’s against gravity

Trunk extensor control develops if baby is given adequate tummy time

Anterior chest wall opens up and becomes more rectangular

Ribs remain fairly horizontal precluding development of intercostal muscles

Increased tidal volume and decreased respiratory rate

Baby remains primarily diaphragmatic breather

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3-6 Months • Chest cavity is

more rectangular shaped

• Ribs remain fairly horizontal until baby begins sitting independently.

6-12 Months What Happens in Normal Development

Baby begins sitting. Antigravity control means strength in all muscles of trunk are above a fair grade (3/5)

Ventilation no longer impacted by contact with supporting surface in prone

Gravity and developing trunk muscles pull and rotate the ribs down, thereby elongating chest wall, especially lower ribs

Downward rotation of ribs improves overall efficiency and strength of diaphragm, abdominals, and intercostal muscles (think: length-tension curve)

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6-12 Months• Ribs begin to rotate downward

and intercostal spaces are wider.

• This allows for deeper, more efficient breathing patterns

• Rib position also helps the diaphragm to assume a more dome-shape at rest.

Let’s Take a Closer Look at the Diaphragm, Intercostals and Abdominals

Lateral, anterior and posterior fibers of diaphragm attach to the lower borders of the ribs 8, 9, and 10 in a ring

As ribs rotate downward the diaphragm becomes domed shaped, allowing for greater excursion with contraction -> stronger diaphragmatic contractions

Abdominal viscera supported by strong abdominal muscles provide intra-abdominal pressure up on the diaphragm for more effective diaphragmatic breathing and for coughing, by helping diaphragm to relax in a domed position.

Intercostal spacing increases with downward rotation of ribs, allowing them to stabilize chest wall and expand laterally and anteriorly during inhalation

Intercostal muscles also help compress chest wall during coughing

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Diaphragm attaches to the ribs in a complete ring

What’s so important about the Diaphragm? • Note the position of the

esophagus passing through the diaphragm.

• This is also the exact point of the Gastro-Esophageal Sphincter.

• A dome-shaped diaphragm, when it contracts, helps to close off the GE sphincter, thereby decreasing reflux.

• A more horizontally (flat) shaped diaphragm does not contract strongly enough to assist with closure of the sphincter.

• This results in greater chance of GE reflux, especially with supine lying and trunk flexion.

View from below.

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Action of the Diaphragmhttps://www.youtube.com/watch?v=Fn3W1xJ8ERo

Diaphragm is relaxed on exhalation and rises up into dome shape. GE sphincter is more relaxed with exhalation.

Diaphragm is contracting on inhalation and flattens out, this closes off the GE sphincter with every breath if there is excursion of the muscle

GE sphincter

The Bottom Line with Typical Infant Development and Reflux

All infants will experience reflux due to anatomical alignment of ribs, decreased diaphragmatic excursion and strength, short esophagus during first 6 months of life

Attainment of independent sitting balance often results in significant reduction of reflux in infants

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Impact of Cultural Practices on Infant Reflux4,5

“Breast is Best” promoted in developing countries –often changes in US with WIC programs providing formula, concerns with weight gain

Exclusive breast feeding often becomes mixed feeding by 2 months of age

Working mothers versus stay at home mothers – responsiveness to babies needs/schedules for sleep and feeding

Feeding Practices Sleep Management

Sensory Nourishment On Demand vs. Schedule

Infant Reflux Excessive Crying5

Baby holding vs. Baby Seat

Breast feeding on Demand

Co-Sleeping

Formula scheduled feeding

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Understanding Reflux in Children with Medical Complexities

G-tube

Down Syndrome

Cerebral Palsy

Reflux in Babies with Down Syndrome6

Trisomy 21 77% of all neonates with DS have

GI concerns

19% require hospitalizations related to GI issues

Most common issue is GERD

Related to delayed motility, hypotonia, strictures in GI system

Often under or mis-diagnosed

Results in growth retardation, respiratory complications

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Reflux in Children with Neurological Impairments7

Cerebral Palsy Unique Challenges

38-57% prevalence in first year of life

Poor postural control of head and trunk, positioning

Decreased oral motor control

Increased or decreased muscle tone

Reflexive movements of head, jaw, tongue

Medications, arousal state, GMFCS Levels

Reflux after Naso-Gastric Tubes

NG tube especially if greater than 4 weeks

• Prevalence of GERD in premature infants with NG tube placement in stomach increased 50%

• Mechanical reason:

• GE sphincter matures around the NG tube when it contracts

• When tube removed GE sphincter contracts the same as when tube was in place –muscle training

• Results in a “hole” in the sphincter from position of NG tube

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Reflux after NICU

Sensory/motor reasons

• Premature or Immature GI and Respiratory systems

• Neurological concerns

• Surgical, medical interventions (intubation, medications)

• Sensory Overload

Reflux in Infants with Tracheostomy7,8,9

50% Infant cardiac patients have reflux

Premies = 50% of all infant trachs are in premies

• Dysphagia in 80% of Infant/Toddlers with tracheostomies • 75% of all Infants with trachs require nutritional support, via Naso-gastric

or Gastrostomy-tube

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Reflux in Older Children with Tracheostomy7,8,9

• 20-50% of Infants with Craniofacial anomalies require tracheostomies• Open tracheostomy poor postural control• Use of one way Passy Muir Valve allows ability to close airway to

create internal pressures• Mary Massery relates to the Soda Can• Closed system is strong and can’t be crushed• Open system and it can be crushed with very little force

A Word about Passy Muir Valves – They Are Not Just for Talking!

• Use of Passy Muir Valve improves diaphragmatic control for pressure management and postural control in upright

• Introduce Passy Muir Valve while monitoring O2 and Resp Rate short periods

• Assess behavior – quiet alert vs distressed

• Assess reflux – less frequent, may be generated with more force in cough

• Assess postural control with and without PMV

• Increase ability to reach up with arms above shoulder level

• More consistent sitting balance, more willing to stand up, less anxiety

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Consequences of Reflux

Feeding refusals, sour breath, infant distress

Inconsistent sitting balance when reflux is active – abdominals ‘shut-off’

Reflux esophagitis, dysphagia, apneic episodes

Recurrent respiratory complications, ‘asthma’, ear infections

Consequences of Reflux

Sensory Defensiveness, Picky Eaters

• Reflux discomfort quickly becomes associated with foods

• Colicky babies, difficult to sooth

• Parental frustration, need for support and advice

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Sandifer’s Syndrome• Paroxysmal Dystonic Movement

Disorder

• Occurs in association with GER

• Characterized by abnormal posturing of the head and neck (torticollis) and severe arching of the spine

• Episodes can last 1-3 minutes, occur up to 10 times per day

• Usually associated with ingestion of food

• Vomiting, anemia, epigastric discomfort, abnormal eye movements and reflux esophagitis may be present

• Posturing may be attempt to relieve gastric pain

• Often misdiagnosed as seizure activity or paroxysmal dystonia

• Elimination of GER resolves abnormal posturing

Consequences of Reflux

• Avoidance of trunk flexion or reaching against gravity continued abdominal weakness

• Posturing in extension and right cervical rotation to relieve intra-abdominal pressure

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Reflux and G-tubes with or without Fundoplication

• Placement of gastrostomy feeding tube is required with severe GERD and failure to thrive

• Fundoplication is often done if risk of aspiration• Fundus of the stomach is wrapped around the lower

sphincter of the esophagus to help close

A Word About G-tubes and Reflux Formulas are prescribed based on

calories and nutritional needs

Organic and non-dairy formulas are now available by prescription

Families may make their own g-tube feeding with support of GI and nutritionist

Reflux may continue after G-tube placement

If reflux persists, try giving bolus of water equal to feeding 30 minutes prior to g-tube feeding

Expands stomach

Water is absorbed quickly

Excessive stomach acid reduced by water

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Tricks and Techniques for the Typical Baby with Reflux10,11

Elimination of Cow’s Milk Protein

Maternal/Infant

Frequent burps

Smaller more frequent feedings

Thickened feeding

No water or thin liquids after

thickened feeds

Give equal amount of water as feeding 30 minutes prior to g-tube or bottle feeds

Positioning:Upright during/after feeding

Prone or left side positioning with supervision after feeding

(caregiver’s lap)

Parental Reassurance and Support

Refer to Pediatrician/GI

If no improvement

Therapy treatment suggestions

Strengthen abdominal muscles on an empty stomach - teach family!

Slow reverse pull to sit with every diaper change but before feedings for consistency and frequency – progress to regular pull to sit

Active reaching, hands to midline, hands to feet play, lifting feet from surface

Straddle sit on parent lap or holding baby with legs around waist, reaching to both sides

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Therapy treatment suggestions

If baby doesn’t want to activate abdominals, try placing baby on incline at first, then progress lower to more horizontal positions

Look at those Abs!

Don’t do this on a

full tummy!

Work-outs before Feeding!

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Tummy Time – Start Early, Do Often!

• Activate trunk extensors while lower costal borders are resting on surface • Elongates ribcage, intercostal spacing• Supports diaphragm externally• Prone positioning reduces reflux in infants – note NICU positioning

Tricks to Keep Tummy Time Fun Reduce use of “containers”

(baby seats) - leave the car seat in the car!

Starting at birth, during every diaper change, place baby on tummy for a few minutes

Hold baby prone across your lap, while you watch TV, sit in church, wait in the doctor’s office

Hold baby on your shoulder often and alternate shoulders

Use the football hold

Prop up over the arm of the sofa or stuffed easy chair

Tummy time whenever awake

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External support to promote abdominals and diaphragm

• Try taping to support obliques and bring lower costal borders down

• Simple elastic abdominal binders extending from lower costal borders to pelvis

• Neoprene vests to provide stronger support and allow cocontraction of core muscles

A Word About Thoraco-Lumbar-Sacral Orthoses

• TLSOs all need abdominal relief to allow normal excursion of diaphragm

• Cutouts should be expanded and/or customized to follow the lower costal borders

• Cutouts need an elastic gusset to provide external support to viscera

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Ribcage stretching to increase diaphragmatic control

• Place hands gently but firmly around lower costal borders• Direction of stretch is towards pelvis, not squeezing• Allow traction to gently follow breathing• Continue for several minutes if possible• Easy to teach caregivers• Infants and toddlers are often ‘squirmy’ until you start then become

very calm and attentive

Infant with Tracheostomy Ribcage Stretching

Normal breathing

Facilitated diaphragmatic breathing

• Introduce Passy Muir Valve• Monitor O2 and Resp Rate• Assess behavior – quiet alert vs

distressed• Assess postural control with and

without PMV

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Mary Pengelley, PT, DPT, ATPpenge@safeaccess.com

Q&A

References1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, et al. Pediatric Gastroesophageal Reflux Clinical Practice

Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2018; 66: 516–54

2. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci. 2017;18(8):1671. Published 2017 Aug 1. doi:10.3390/ijms18081671

3. Jenifer R. Lightdale, David A. Gremse. Gastroesophageal Reflux: Management Guidance for the Pediatrician, Pediatrics May 2013, 131 (5) e1684-e1695; DOI: 10.1542/peds.2013-0421

4. Suzinne Pak-Gorstein, Aliya Haq, Elinor A. Graham. Cultural Influences on Infant Feeding Practices. Pediatrics in Review Mar 2009, 30 (3) e11-e21; DOI: 10.1542/pir.30-3-e11

5. Pamela S. Douglas. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Medical Hypotheses, Volume 64, Issue 5, 2005, Pages 887-898.

6. Macchini F, Leva E, Torricelli M, Valadè A. Treating acid reflux disease in patients with Down syndrome: pharmacological and physiological approaches. Clin Exp Gastroenterol. 2011;4:19-22.

7. Sullivan PB, Lambert B, Rose M, Ford‐Adams M, Johnson A, Griffiths P. Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford Feeding Study. Dev Med Child Neurol 2000; 42: 674–80.

8. Ibrahim J. et al. Outcome of tracheostomy after pediatric cardiac surgery. Journal of the Saudi Heart Association, Volume 24, Issue 3, 2012, Pages 163-168.

9. Vivienne Norman, Brenda Louw, Alta Kritzinger. Incidence and description of dysphagia in infants and toddlers with tracheostomies: A retrospective review, International Journal of Pediatric Otorhinolaryngology, Volume 71, Issue 7, 2007, Pages 1087-1092.

10. Mahida JB, Asti L, Boss EF, et al. Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality Improvement Program Pediatric. JAMA Otolaryngol Head Neck Surg. 2016;142(3):241–246. doi:10.1001/jamaoto.2015.3302

11. Salvatore S, Abkari A, Cai W, et al. Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants[published online ahead of print, 2018 May 25]. Acta Paediatr. 2018;107(9):1512–1520. doi:10.1111/apa.14378