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5/9/2005 Gastroesophageal Reflux in Young Children Pamela Tyler, M.S., CCC SLP, Independent Contractor, Volunteer, Pediatric/Adolescent Gastroesophageal Reflux Association (PAGER) | |
| Introduction: Gastroesophageal reflux is the backwashing of stomach contents and stomach acid into the esophagus due to inappropriate relaxation of the lower esophageal sphincter (LES). Gastroesophageal reflux (GER) is also known as acid reflux or heartburn. If acid reflux causes damage to the esophagus, it is referred to as Gastroesophageal Reflux Disease (GERD). Pediatrics, GER and GERD: Many infants “spit-up.” Approximately 50% of 0-3 month olds have at least one episode of Gastroesophageal reflux per day. This increases to a peak of 67% of infants at 4 months of age. (Department of Otolaryngology, University of Texas Medical Branch. 2000, October). It is estimated that 5 to 8 percent of young children develop Gastroesophageal Reflux Disease. This percentage rises considerably in young children with motor, neurological and developmental problems, estimated at 50-80 percent in those populations (Burns, 2003). Medical diagnoses associated with a higher incidence of GERD include: Down Syndrome, Cerebral Palsy, Autism, Rubinstein Taybi Syndrome, Cystic Fibrosis and Cornelia de Lange Syndrome. Premature infants are also more susceptible to GERD. Despite the prevalence in young children, the symptoms of GERD are often overlooked, or sometimes misdiagnosed as “colic.” Categories of Symptoms related to Pediatric Gastroesophageal Reflux Disease: I. Pain
Testing and Diagnosis of Pediatric Gastroesophageal Reflux Disease: GERD can be diagnosed solely by observation of symptoms, but sophisticated medical tests may sometimes be warranted. Although a poor test for reflux itself, a barium swallow and/or upper gastrointestinal x-ray (Upper GI) is often used to look for structural problems such as; hiatal hernia, pyloric stenosis and/or malrotation of the intestine -- which may result in obstruction causing GERD symptoms. A pH probe measures the frequency and degree of reflux. Scintography (milk scan) measures the amount of time it takes the stomach to empty. Slow gastric emptying can contribute to reflux. This test can also show aspiration of refluxed material into the lungs. Upper endoscopy looks for abnormalities and damage to the esophagus. A multiplicity of other disorders, with symptoms similar to Gastroesophageal Reflux may need to be ruled out, including;
There are many treatment regimens and protocols for GER and GERD, depending on the suspected etiology and the degree of dysfunction or discomfort. Diet, positioning and medication often reduce or eliminate symptoms and greatly reduce pain. However, concurrent food allergies, food intolerances, oral motor problems and medical or developmental conditions may render treatment of GERD extremely complex. Please note, it is important to consult with the child’s pediatrician before making or following any recommendations for individual children. Diet Considerations: With infants, breastfeeding is encouraged as breast milk is digested more quickly, is more “intestine-friendly” and contains a natural antacid. The breastfeeding mother may note that in certain children, the introduction of dairy, soy, wheat and chocolate products into the mother’s nutritional regimen may irritate the baby. Instituting an elimination diet of these irritating foods can elevate symptoms. Formula fed infants who may be allergic or intolerant of milk and soy proteins may benefit from a casein hydrolysate formula such as Alimentum, Nutramigen, or Pregestimil or an amino-acid based formula such as NeoCate or EleCare Thickened feedings are often recommended but can have contra-indications including aspiration and greater difficulty sucking. Smaller more frequent feedings are also recommended for symptomatic children. When feeding, minimizing air swallowing and gas by making sure the infant has adequate latch on breast or bottle nipple, burping often and efficiently and using bottles that reduce air intake (for example; Dr. Brown’s and Avent brands) can be helpful. Offering non-nutritive sucking opportunities may also be helpful as increased salvia production eases irritation and speeds gastric emptying. Older children benefit from avoiding foods high in acid or irritants such as chocolate, caffeine, tomatoes, orange juice, carbonated beverages and certain spices such as peppermint and hot pepper. High fat, fried, stringy foods as well as seeds and skins may slow digestion and cause painful bloating. Older children should be encouraged to eat slowly and chew food well. They may also benefit from smaller more frequent meals, avoiding eating before naps and bed time, and not drinking and eating at the same meal to prevent abdominal pain and discomfort. Positioning: In general, try to keep the young child semi-upright during and immediately following feedings. Positioning the young child completely upright may compress the stomach and digestive organs causing increased discomfort. Some infants find great comfort positioned in a carrier such as a “Snugli” after eating. Breastfeeding mothers may find using a reclined cradle hold or lying “stomach to stomach” while breastfeeding is more effective for reducing GER or GERD (Le Leche League, 1999). Following feedings, the child should not participate in vigorous activity to allow thorough digestion. Having the young child wear loose fitting clothing and diapers can keep pressure away from the abdomen. Many young children feel the discomfort of GERD maximally while sleeping. It may help to elevate their head 30 degrees with a wedge, “Tucker sling” or “Amby bed.” While it is safest for infants under 6 months to sleep on their backs, some infants with GERD sleep better on their stomach or left side. Stomach/left side sleeping positions may be recommended for infants at risk for aspiration. Medication: There are numerous categories of medications used to treat GER and GERD. Often physicians use a trial of various medications often within the same category before finding the most effective medication and sometimes a combination of medications is required. For example, adding a dose of Histamine (H-2) blockers to a regimen of Proton Pump Inhibitors can sometimes help control nighttime discomfort (Rackoff, 2004). Timing of medication administration can be critical for optimum results and in young children it is important to monitor and adjust dosage frequently as the child grows. Medications often metabolize faster in young children, therefore, they may require more frequent or larger doses for optimum effectiveness. It is important to be aware some medications have ingredients which can cause aggravation of symptoms. “Zantac” has ingredients that may cause nausea or vomiting (Evans-Morris & Klein, 2001) and its peppermint flavoring might irritate the esophagus in some individuals. “Prilosec” contains milk-based ingredients that can aggravate those young children who are intolerant of dairy products. Medications used to treat GERD:  Surgery: Surgical solutions are rarely used, but in severe to profound cases of GER and GERD, if deemed appropriate by the physicians, surgical options are available. Surgery is typically only considered after diet, positioning and medications have been shown to be ineffective in a particular child, and if symptoms adversely affect the child’s overall health. Fundoplication surgery can tighten the juncture of the esophagus at the stomach. A band of upper stomach muscle is wrapped totally (Nissan) or partially (Thal) around the lower esophagus. However, following surgery, the young child may lose their protective ability to vomit, burp or retch, which can introduce additional risks to the situation. Nonetheless, when applied, surgery is considered critical in reducing severe esophageal damage and reducing the risk of aspiration. Effects of Gastroesophageal Reflux on Feeding Development: Young children quickly learn to associate the pain of GER and GERD with feeding. If GERD is under-diagnosed and/or under-treated for long periods of time, a young child may develop secondary behavioral symptoms of food refusal, selectivity and oral sensitivity which can negatively impact growth and maturation and can lead to delayed acquisition of feeding skills. Young children with GERD may be hypersensitive to tactile sensations therefore do not explore objects with their mouths, which can lead to a lag in the development of the oral sensori-motor skills required for feeding. Introduction of spoon feeding may be delayed due to lack of readiness skills or noted increase of symptoms with introduction of solid foods. Young children also may have difficulty advancing to textured foods and may gag or choke while feeding. These symptoms (i.e., food refusal, selectivity and oral sensitivity) stress the feeding relationship between the young child and caregivers and may lead to counter-productive feeding practices. The associations that young children make between the pain of GERD and feeding can remain even long after the pain of GERD has subsided. Young children may also be taken off medication when the obvious symptoms of reflux disappear yet their reflux may continue silently (meaning that stomach contents go into the esophagus but does not result in vomiting) and cause continued feeding problems. Therefore it is vital that the young child receive proper medical diagnosis and treatment of reflux, especially pain relief, before attempting a feeding intervention program. Without effective pain management, oral-motor, sensory and behavioral feeding interventions may yield disappointing results. Conclusion: Gastroesophageal Reflux resolves in most children by age one year (55%) or eighteen months (81%) (Department of Otolaryngology, UTMB. 2000, October). However, some children present with GERD throughout childhood. It is important for those working with children who have GERD to understand the complexities associated with this disease. In some children, reflux is no more than a minimal problem, and in other it can have significant impact on their health, growth and development. Families of young children with disabilities report that managing GERD and related feeding problems is the hardest part of parenting a young child with a disability. Often, a parent feels like a failure because their child won’t eat/sleep/grow like other children. The caregiver’s burden for this illness is tremendous and can lead to fatigue, depression and even child abuse. As professionals, we need a broad knowledge of GER and GERD to provide parents and other caregivers information, guidance and support, to feed and comfort their children to facilitate maximal development and potential. References: AstraZenecaLP. (n.d.). Introduction to GERD . Retrieved October 30, 2004, from www.gerd.com Bagwell, CE (1995). Gastroesophageal Reflux in Children. Surgery Annal , 27, 146. Blackman. (1990). Medical Aspects of Developmental Disabilities in Children Birth to Three. New York: Aspen Publishers. Burns, J. (2001). Eating problems and Reflux-Home Intervention. Reflux Digest, 1:5(1), 11-13. Burns, J. (2000). Feeding problems and Reflux. Reflux Digest, 4(3), 8-11. Burns, J. (2004, April 24). Gastroesophageal Reflux Disease: A Common but Under-Diagnosed Disease. Speech presented at Maryland Speech Language Hearing Association Annual Convention, Towson, Maryland. Burns, J. (2003, August). PAGER: Pediatric/Adolescent Gastroesophageal Reflux Association Exceptional Parent Magazine, 33 (8), 64-67. Department of Otolaryngology, University of Texas Medical Branch. (2000, October). Pediatric Gastroesophageal Reflux Disease. [Pamphlet]. Galveston, TX: Rosen, Frederick S. Eicher, P. (2002, July 19). Advanced Topics in Pediatric Gastroesophageal Reflux Disease: Beyond the Silver Spoon: Developmental Perspectives in Feeding and Swallowing. Speech presented for PAGER members, Chester County, Pennsylvania. Evans-Morris, S, Dunn-Klein, M. (2001). Pre-Feeding Skills. Tucson, AZ : Therapy Skills Builders. Gallup Organization, the. (1988). A Gallup Organization National Survey: Heartburn Across America. Princeton, NJ: Gallup Organization, the. Guidelines for evaluation and treatment of Gastroesophageal Reflux in infants and children. Recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. (2001). Journal of Pediatric Gastroenterology and Nutrition, 32, 2, suppl. Hyman, PE, Orenstein, SR. (1994). Gastroesophageal Reflux Pediatric Gastrointestinal Motility Disorders. New York: Academy Professional Information Services. La Leche League International. (1999). Breastfeeding the Baby with Reflux. [Pamphlet]. Schaumburg, IL: Barmby, Laura. Macht, J. (1990). Poor Eaters: Helping Children Who Refuse to Eat. New York: Plenum Press. Mathisen, B.; Worell,L.; Masel,J.; Wall,C.; Shepherd,R.W. (1999, April). Feeding Problems in Infants with Gastro-oesophageal Reflux Disease: A Controlled Study.” Journal of Paediatrics and Child Health, 35,163-169. Nebel OT, Fornes MF, Castell DO. (1976) Symptomatic Gastroesophageal Reflux: Incidence and Precipitating Factors. American Digest of Digestive Disorders, 21(11), 953-956. Nelson, SP, Chen, EH, Syniar, GM, et.al. (2000). Prevalence of Symptoms of Gastroesophageal Reflux during Childhood: a Pediatric Practice-Based Survey. Pediatric Adolescent Medicine, 154, 150-4. Orenstein, SR. (1993). Reliability and Validity of an Infant Gastroesophageal Reflux Questionnaire. Clinical Pediatrics, 172-184. PAGER Association. (2001). Going to School with Acid Reflux. [Pamphlet]. Buckeystown, MD: Burns, Jan. PAGER Association. (2004). Medications for Pediatric GER [Pamphlet]. Buckeystown, MD: Anderson, Beth. Rackoff, Andrew. (2004). Histamine-2 Receptor Antagonist at Night Improve GERD Symptoms for Patients on Proton Pump Inhibitor therapy. [Abstract]. American Journal of Gastroenterology, 99, 52. Sears, William. (2003, January). GER: What is it; what to do: FAQ’s. 42 paragraphs. Retrieved October 30, 2004, from www.askdrsears.com/html/10/t106004.asp Spechler SJ. (1992). Epidemiology and Natural History of Gastro-esophageal Reflux Disease. Digestion, 51(suppl 1), 24-29. Ze Hu, F, Preston, R. et.al. (2000). Mapping the Gene for Severe Pediatric Gastroesophageal Reflux to Chromosome 13q14. JAMA, 284,325-334. Pediatric Adolescent Gastroesophageal Reflux Association (PAGER Association) PAGER Association has been providing information and support to parents, grandparents, friends and professionals for 12 years. Located in Buckeystown, Maryland, PAGER maintains an information rich website and discussion board. PAGER also has a quarterly newsletter, booklets, pamphlets, videos, parent/professional conferences and a parent warm line for questions and concerns. To contact PAGER Association: PO Box 486 Buckeystown, MD 21717-0486 (301) 601-9541 message center gergroup@aol.com www.reflux.org | |