Transcript 4-Regurgitation Lifschitz

Regurgitating infants: what to do?
Prof. CARLOS H. LIFSCHITZ
Associate Physician,
Pediatric Gastroenterology,
Italian Hospital, Buenos Aires, Argentina
Former Associate Professor,
Baylor College of Medicine, Houston, Texas
Esophagus
•
A muscular tube with peristaltic contraction transporting food
to the stomach
• Upper 1/3: Skeletal Muscle, voluntary control
• Lower 2/3: Smooth Muscle, involuntary control
• Lower Esophageal Sphincter is tonically contracted smooth
muscle at the distal esophagus that relaxes to allow passage of
food.
Antireflux barrier
Factors that prevent GER (esophageal)
• LES tone
•
• Esophageal clearance
•
• Gravity
•
• Buffering by saliva
Factors that prevent GER
(non esophageal factors)
• Diaphragmatic pressure
• G-E “Angle of HIS”
•
• Abdominal-thoracic pressure difference
•
• Phreno-esophageal ligament
•
• Gastric emptying
Gastroesophageal Reflux
• Effortless involuntary passage of stomach
contents into the esophagus
• When high enough to be visualized:
regurgitation
• May or may not be symptomatic, depending on
the acidity of reflux
• Accounts for approximately 20% of Pedi-GI
referrals
Vomiting
• A central nervous system reflex involving both
autonomic and skeletal muscles in which
gastric contents are forcefully expelled through
the mouth because of coordinated movements
of the small bowel, stomach, esophagus, and
diaphragm.
Rumination
• Previously swallowed food is returned to the pharynx
and mouth, chewed, and swallowed again.
Gastroesophageal reflux disease
Regurgitation of gastric contents causes complications or
contributes to tissue damage or inflammation:
•
esophagitis,
•
obstructive apnea,
•
reactive airway disease,
•
pulmonary aspiration,
•
feeding and swallowing difficulties, or
•
failure to thrive
Transient LES Relaxations
Pharynx
UES
Esophagus
Crural
diaphragm
Pylorus
Angle
of His
LES
Stomach
Tracings reprinted from Kawahara et al, Gastroenterology 1997;113:399
Normal GER
• 5 episodes/hr < 2 hr postprandial
• Reflux +++ in upright in normals (sudden pH drop,
stepwise return)
• Rarely reflux while asleep (50% gradual drift)
• ∆ prone → supine GER ⇑ x 7
Vandenplas J Ped Gas Nut 85;4:356
Functional GER
(“Infantile”, “Physiologic”)
• Begins before 3 months of age
•
• Not during sleep
•
• Normal growth
•
• No symptoms except effortless reflux
•
• Improves after 6 months of age
Prevalence of Regurgitation
in Infancy
 1 time a day
 4 times a day
% of
Infants
0-3
4-6
7-9
Age (months)
Adapted from Nelson et al, Arch Pediatr Adolesc Med 1997;151:569
10-12
Prevalence
100
67
75
61
*70%
50
50
%
20
13%
5
25
0
0
3
4 months 6
8
12
GERD <3%
VLBW, respiratory distress, neurological problems
Vandenplas Y. Acta Ped 1998; 87:462; *Nelson SP. Arch Ped Ad Med. 1997; 151:569
Natural history & familial relationships
of infant spilling to 9 yr. of age.
Martin AJ et al. Pediatrics 2002;109:1061
• AIMS: To determine:
natural h/o infant spilling during first 2 yr. of
life and
• the relationship between infant spilling and
GER symptoms at 9 yr. of age.
• METHODS: Cohort followed with daily symptom
diaries from birth to 3 yr. of life and reviewed at
9 yr of age
•
Natural history & familial relationships of infant
spilling to 9 yr. of age.
Martin AJ et al. Pediatrics 2002;109:1061
• RESULTS: 693 children (83% of original sample)
• Infants with spilling on ≥ 90 d during first 2 yr. of life more
likely to have GER symptoms at 9 yr of age
• relative risk of 2.3 of 1 or > GER symptoms at 9 yr. of age
• 4.6 for heartburn
• 2.7 for vomiting and
• 4.7 for acid regurgitation.
• Prepregnancy smoking and smoking in same room as
child @ 9 & 18-mo. significant effect on GER symptoms
at 9 yr. of age.
Natural History and Familial Relationships of
Infant Spilling to 9 Years of Age.
Proportion of children with
spitting up
Martin JA. PEDIATRICS. 2002; 109:1061
Gastroesphageal Reflux
• There is a lack of correlation between crying,
irritability, and GER.
• GER is not a common cause of unexplained crying,
irritability, or distressed behavior in otherwise healthy
infants.
Diagnosis
•
•
•
•
•
•
History
Physical examination
Upper GI (false+ 31%, False– 14%)
r/o pyloric outlet obstruction; esophageal stenosis,
pyloric stenosis, duodenal web, malrotation
“milk” scan
Upper endoscopy
pH probe
•
•
•
•
1. Calibration
2. Position of probe tip by:
• Mathematical formula
• Manometrics
• Radiology
3. Recording
• 24 hours
4. Diary
GER –pH probe
•
<2 hour postprandial: early GER, physiologic is prevalent
•
>2 hour postprandial: late GER associated with delayed
gastric emptying
•
Feedings with acid pH, reflux-promoting foods, liquid >
solids, acid pH medications, chest PT, tracheal suctioning,
coughing
Physiologic Gastroesophageal Reflux
(Mean upper limit of normal)
Infants
(N=509)
Children
(N=48)
Adults
(N=432)
No. of daily reflux episodes
73
25
45
No. of reflux episodes > 5 min
9.7
6.8
3.2
Reflux index (% of time pH < 4)
11.7%
5.4%
6%
Vandenplas Y, Pediatrics 1991;88:834-40
Sondheimer J J Pediatr 1980;96:804-7
pH Probe
• Pathologic acid reflux does not correlate consistently
with symptom severity or demonstrable complications.
• useful for evaluating efficacy of antisecretory therapy
• may be useful to correlate symptoms (eg, cough, chest
pain) with acid reflux episodes and to select those
infants and children with wheezing or respiratory
symptoms in whom GER is an aggravating factor.
• Sensitivity, specificity, and clinical utility of pH
monitoring for diagnosis and management of possible
extraesophageal complications of GER are not well
established.
WHAT IS IMPEDANCE ?
Opposition to Current Flow
Inverse measurement of the electrical conductivity of
an organ’s wall & contents
WHY DOES IMPEDANCE CHANGE?
No bolus = few ions = high impedance
Bolus present = many ions = low impedance
IMPEDANCE RANGE
Low Conductivity = High Impedance
Air (high)
Esophageal Lining
Saliva
Food
Refluxate (low)
Impedance –pH Catheter
Pediatric Model
13 cm
11 cm
6 impedance channels
1 pH channel
9 cm
7 cm
5 cm
3 cm
pH – 3 cm
9
I
m
p
e
d
a
n
c
e
Bolus Present
Bolus entry
Bolus exit
Time
Impedance Ring Set
MII Detected Bolus Movement
Antegrade
Retrograde
Swallow.
Reflux
GE Reflux Episode
Symptom
37
What can we do with MII-pH?
•
Measure acid - weakly acid and non-acid reflux
•
Correlate acid and non acid reflux to symptoms
•
Determine height of proximal migration
Benefits of MII over pH probe
• Evaluate patient with persistent symptoms while on PPI
• Evaluate atypical GERD
• Correlate acid & non-acid GER episodes with symptoms
• Quantify proximal extent of GER
• Evaluate postprandial GER
•
•
pH is blind during early postprandial period
Postprandial is prime time for reflux and symptom occurrence
Clinical Benefits
•
MII-pH Monitoring detects all reflux during the entire analyzed
time period
•
Symptom correlations are made with both acid and nonacid
reflux
•
MII-pH Monitoring sensitivity is not compromised during the
postprandial time period.
•
A true postprandial reflux study is possible
Acute Life Threatening Event
1. How long did the event last?
2. Did the infant stop breathing?
3. If yes, did he continue making respiratory efforts?
4. Was the infant’s heart beating?
5. Was stimulation required to resolve the ALTE?
6. Was there a color change noted?
7. Did the infant choke, gag or vomit with the event?
8. Were there any abnormal movements (stiff or limp extremities)
associated with the event?
9. Was there any evidence of recent fevers or illness?
Apnea during GER
Apnea preceding GER
Apnea following GER
ALTE
•
If 24hr Ph-MII suggests a temporal association between reflux
and the ALTE, management options include:
•
•
acid suppression therapy and
thickening of feeds.
In very severe cases where recurrent ALTE episodes occur,
surgery may be considered.
Influence of Xanthines on GER
• # episodes GER increased (p<0.01) in ~ 50% of treated
with caffeine and
• 66% with theophyline, independently of plasma xanthine
concentrations and efficacy of the drug
• Increase in number of episodes of GER in 24 hrs. (from 5.3
to 17.1 in the caffeine group and from 5.3 to 24.3 in the
theophylline group) and
• for the time pH was < 4 (from 0.87% to 6% in the caffeine
group and up to 13% in the theophylline group).
Vandenplas Y Pediatr ’86;77:807
age of
ofonset
onset >>11 week
weekor
or << 66 months
months
age
Regurgitation
No
refer
Yes
No
episodes, daily for > 1 week
>>44episodes,
week
Yes
Feeding frequency/volume/technique
check and correct if needed
Improvement?
No
Follow-up
•• Reassure
Reassure parents
parents
•• AR-formula
AR-formula
•• Positional
Positionaltreatment
treatment??
No
Yes
Improvement?
Yes
Follow-up
Yes
there also:
also:
IsIs there
•• Vomiting
Vomiting ??
•
Irritability/crying
• Irritability/crying ??
•• Fussiness
Fussiness ??
•• Feeding
Feeding problems?
problems?
•• Atopic
Atopic dermatitis?
dermatitis? Eczema?
Eczema?
•• Constipation
Constipation ?? Diarrhea
Diarrhea ??
•• Sleeping
Sleeping problems?
problems?
•• CoMiSS
CoMiSS >> 12
12 **
Is there also:
• Failure to thrive?
• Hematemesis ?
• Back arching / Sandifer ?
• Neurological abnormalities ?
• Neurodevelopmental delay ?
No
Yes
No
Consider
Consider CMPA
CMPA
•••Consider
Consider
CMPA
CMPA
CMfree
CMfree diet
in BF
•••CMfree
CMfree
diet in
BF
BF
(thickened)eHF
FF
•••(thickened)
(thickened)
eHF 2-4
2-4 weeks
weeks
weeksin
in
inFF
FF
* CoMiSS: awareness tool for cow’s milk related
symptoms (Acta Paed 2015) needs still validation
Improvement?
Yes
AR-formula: anti-regurgitation formula; BF: breastfed; FF: fomula fed; eHF: extensively hydrolysed formula
No
•• Refer
Refer patient
patient to
to specilality
specilality consultation
consultation
• Consider GERD, eosinophilic
esophagitis,
esophagitis, anatomical
anatomical anomalies
anomalies
Challenge and follow-up
according to CMPA
Management of regurgitation
• Conservative measures include positioning after
meals and thickened feedings which can decrease
regurgitation in healthy infants.
• While frequent smaller-volume feedings are
sometimes recommended, there is little direct
evidence to support the efficacy of this approach.
• Postprandial left-sided and prone position reduces
regurgitation.
Positioning
NO:
All day upright
Seated
Car Seats
Prone
YES:
Supine
Elevation of head of bed
Infant seat and GER
Orenstein et al. N Eng J Med ’83;309:760
• n=9, < 6 mo.; 8 paired two-hour postprandial trials
• longer exposure to GER while infants were in the seat
than when they were prone (28.2 +/- 6.4 % vs. 12.8 +/3.7 % of total time with pH less than 4.0, P = 0.023), a
difference due largely to
• more episodes (16.0 +/- 2.4 vs. 10.1 +/- 2.3 per 2-hr
postprandial period, P = 0.002).
Decrease in Symptoms (%)
Significant Changes in Symptoms
% Feeds
Daily total
followed by regurgitation
regurgitation volume score
% Feeds
choke/
gag/cough
% Feeds
trouble
sleeping
Metoclopramide:
frequency and volume of vomiting
•
Four controlled trials in children
•
Two: benefit on frequency and volume of
vomiting (Leung C et al. Curr Ther Res 1984; 36:911.52; De
Loore I et al. Postgrad Med J 1979; 55:40)
•
Two: similar to placebo (Machida HM et al. J Pediatr
1988; 112:483; Bellissant E et al. Clin Pharmacol Ther 1997; 61:377).
Metoclopramide
•
Cochrane review of 7 trials evaluating metoclopramide for GERD in
children < 2 yr. of age, including the 4 controlled trials mentioned
before:
•
some benefit in comparison to placebo, but
at the expense of increased side effects.
Craig WR. Cochrane Database Syst Rev 2004; CD003502.
Domperidone
•
•
D2-blocker with selective peripheral activity in the upper
gastrointestinal tract.
Its major advantage is that it does not cross the blood-brain barrier
and, therefore, lacks the neurologic side effects of metoclopramide.
Domperidone
• Two controlled trials with a total of 107 infants concluded that
domperidone drops or suppositories were more effective than
was placebo or metoclopramide in controlling nausea, vomiting,
and regurgitation (De Loore I et al. Postgrad Med J 1979; 55:40; Van
Eygen M et al. Postgrad Med J 1979; 55 (Suppl 1):36)
• Two other studies found no improvement in any of these
measures after 4 and 8 wk. of therapy (Bines JE et al. J Pediatr
Gastroenterol Nutr 1992; 14:400; Carroccio A et al. Scand J Gastroenterol
1994; 29:300).
Algorythm 1- Recurrent emesis
Alarm Signs?
No
Yes
Reassurance
Happy spitter
No tests needed
formula AR?
Reassess at 12 mo.
infant
yes
Resolved?
No
NASPGHAN Guidelines JPGN 2001; Suppl.2:S1-S1-S31
Algorythm 3- Irritability
GER ?
possible
Hydrolyzed formula,
AR recs, H2 Blockers
infant
* No
Resolved?
Yes
Esophagitis
Negative?
Look for another cause
* at 18-24 mo.
NASPGHAN Guidelines JPGN 2001; Suppl.2:S1-S1-S31
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