GastroesophagealReflux in Infants and Children

Swallowing reflex begins at 16 weeks gestation

Can suckle by 2nd to 3rd trimester

34 weeks, infant can suckle and feed normally

Pharyngeal phase earlier developed

Oral preparatory phase maldeveloped in premature infants

DefinitionsGER Involuntary passage of gastric contents

into esophagus

GERD Symptoms or complications that may occur when gastric contents reflux into esophagus or oropharynx

Regurgitation Passage of refluxed gastric contents into oral pharynx

Vomiting Expulsion of refluxed gastric contents from mouth

What is Gastroesophageal Reflux Disease?

When highly acidic contents of the stomach are refluxed back up to the esophagus These gastric contents irritate and sometimes

damage mucosal surfaces of the esophagus It is a clinical condition that is severe enough

to impact the patient’s life and/or damage the esophagus

Gastroesophageal Reflux in Infants

An infant will throw up after almost every feeding and many times between feedings.

This is usually due to an incoordination or immaturity of the upper respiratory tract.

Parents often worry that something more is wrong with the baby’s stomach Ulcer Not keeping enough food down to grow

The Antireflux Barrier

Transient LES Relaxations

 Tracings reprinted from Kawahara et al, Gastroenterology 1997;113:399

Esophagus

LES

Cruraldiaphragm

Pylorus

Stomach

Angle of His

Pharynx

UES

Esophageal Capacitance

• Shorter esophagus• Smaller capacity

Gravity

Adult

Infant

Airway Protective Mechanisms

ESOPHAGEAL DISTENTION UES contracts

Vagal reflexesVocal cords closeCentral apnea occursUES relaxes

0.15 s

Refluxate enters pharynx0.3 s

Swallowing clears pharynx0.6 s

Small volume

1.0 sRespiration resumes

Large volume

Pathogenic Factors in GERD Mechanisms of GER• Transient LES relaxation• Intra-abdominal pressure• Reduced esophageal capacitance• Gastric compliance• Delayed gastric emptying

Mechanisms of Esophageal Complications• Impaired esophageal clearance• Defective tissue resistance• Noxious composition of refluxate

Mechanisms of Airway Complications• Vagal reflexes• Impaired airway protection

Esophagus

LES

Cruraldiaphragm

Pylorus

Stomach

Angle of His

Pharynx

UES

Common Symptoms

It is unknown whether adults and infants have the same symptoms

Infants are most likely to have: Frequent or recurrent vomiting Heartburn Gas Abdominal pain

Diagnosis

Usually hearing the parents story and seeing the child is enough to determine this problem

A few diagnostic tests that are given when further testing is recommended Barium Swallow or Upper GI series pH Probe Endoscopy

Barium Swallow

X-ray allowing doctors to follow food down the infants esophagus into the intestines

Doctor is able to see if there are twists, kinks, or a narrowing of the upper intestinal tract

Not very reliable

pH Probe

Performed by the use of a small wire with an acid sensor

Starts at the infants nose and ends at the bottom of the esophagus

Sensor is left in place for 12-24 hours The severity of the reflux does not always

correlate with the severity of the symptoms

Esophageal pH Monitoring

•Cannot detect nonacidic reflux

•Cannot detect GER complications associated with “normal” range of GER

•Not useful in detecting association between GER and apnea unless

combined with other techniques

Limitations

•Detects episodes of reflux

•Determines temporal association between acid GER and symptoms

•Determines effectiveness of esophageal clearance mechanisms

•Assesses adequacy of H2RA or PPI dosage in unresponsive patients

Advantages

Endoscopy

A flexible endoscope with lights and lenses are passed through the infants mouth.

Esophagitis Due to repeated exposure of the esophagus to

stomach acid

Less than half of the infants with severe symptoms do not develop esophagitis

Esophagogastroduodenoscopy (EGD)

•Need for sedation or anesthesia

•Endoscopic grading systems not yet validated for pediatrics

•Poor correlation between endoscopic appearance and histopathology

•Generally not useful for extra- esophageal GERD

Limitations

•Enables visualization and biopsy of esophageal epithelium

•Determines presence of esophagitis, other complications

•Discriminates between reflux and non- reflux esophagitis

Advantages

Treatment

Positioning the baby After feeding, put the baby on his stomach, and

elevate the head Changing feeding schedules

Feed baby smaller amounts more often Dietary treatments

Parents are instructed to thicken their infants formula with cereal

Treatment Continued

Medications are used: Lessen intestinal gas Decrease or neutralize

stomach acid Improve intestinal

coordination

Surgery Extremely rare Nissen Fundoplication

Mechanisms of Respiratory Responses to GER

Principles of Antireflux Surgery

Restore intra-abdominal segment

of esophagus

Approximatediaphagmatic

crurae

Reduce hiatal herniawhen present

Wrap fundus around LES to reinforce antireflux barrier

Epiglottic Flap Closure

Glottic Closure

Tracheoesophageal Diversion and Laryngotracheal Separation