Gastroesophageal Reflux

 Definition
 Background
 Diagnosis
 Treatment

Definition

Gastroesophageal reflux (GER) is defined as spontaneous return of gastric contents into the esophagus. It may be regurgitant, with gastric material appearing in the mouth, or non-regurgitant. Non-regurgitant GER may be less obvious, but adverse outcomes may still be present.

Background

Gastroesophageal reflux (GER) and/or aspiration risk appears to be higher in VLBW and LBW infants. While many families report that their infants "spit up," reports of "spitting up" in a preterm infant should not be dismissed out of hand. Pathological reflux or GER disease may be associated with poor growth, esophagitis, irritability, intractable crying, feeding aversions, and respiratory symptoms. Feeding problems due to early experiences with GER may persist beyond the time of resolution of the GER. Aspiration can be a consequence of GER that causes special concern.

In parental focus groups, GER was a common topic brought up by parents. Please see section on What Parents say about Feeding Preterm Infants. It was not uncommon for families to speak of GER type symptoms that impacted feeding and remained undiagnosed for significant periods of time.

It appears reasonable to screen each LBW infant frequently in the first months of life to rule out need for further assessment for GER and/or aspiration.

For more information see Feeding and Swallowing Disorders in Infancy by Wolf and Glass.

Diagnosis

Behaviors

Feranchak and colleagues (1994) examined behaviors of infants who were undergoing esophageal pH monitoring. Documented episodes of reflux were frequently associated with the following behaviors: discomfort as evidenced by crying or frowning, regurgitation, drooling, burping, yawning, stridor, stretching, and mouthing. Some behaviors were only found in some infants. These included hiccupping, sneezing, thumb-sucking, coughing or gagging.

Other behaviors that have been associated with reflux include gagging, coughing, and repeated swallowing between meals, red, teary eyes, and fussiness and irritability 30 to 60 minutes after a feeding. These symptoms can occur for other reasons, which should be ruled out.

Parental Screen

Orenstein et al (1993) developed and validated a parental questionnaire that can be used clinically to assess the likelihood of GER. The entire questionnaire is provided in the August 1993 issue of Clinical Pediatrics.

This group used the questionnaire to compare 35 infants with gastroesophageal reflux disease as documented by pH probe or esophageal suction biopsy and 100 "normal" infants. See Orenstien et al (1996). Some infant behaviors as reported by parents were highly associated with positive diagnosis of GER. These were:

• Spitting up more than three times a day
• Spitting up more than a tablespoon
• Discomfort associated with spitting up
• Crying a lot after feedings
• Crying for more than three hours a day
• Spells of back arching
• Apnea while awake and/or cyanosis

If infant behaviors, growth, and parental report seem to indicate that reflux in an infant is pathological, further investigation is warranted.

pH Probe

The pH probe is considered the "gold standard" for diagnosis of GER. A probe is inserted into an area just above the lower esophageal sphincter. The test is usually done over a 24-hour period and requires a hospital stay. Readings of pH are recorded over the testing period. Data may include total number of episodes with pH <4.0, total time with pH <4.0, number of episodes greater than 5 minutes, and the longest episodes. A reflux score is calculated and compared to normal values to make the diagnosis of reflux. Reflux that occurs immediately following a meal may be missed with the pH probe if the acidity of gastric contents is not below a pH of 4.

Technicium Scan

The infant is given a feeding that contains a radiopharmaceutical that will allow visualization of the position of labeled materials every 30 seconds. This method will pick up less acidic material that may reflux to the esophagus, and may also detect aspiration of gastric contents into the bronchial tree.

Treatment

• Positioning
• Timing of Feedings
• Thickened Feedings
• Medications
• Surgical Management

Positioning

This intervention is a mainstay of non-invasive treatment for GER. Positive benefits are thought to be due to the effects of gravity as well as changes in lower esophageal sphincter (LES) pressure. Positioning changes are usually individualized. Frequently suggested changes include:

• Positioning at no less than a 45 degree angle during feeding at the breast or with the bottle.
• Positioning on a foam "wedge" during sleep and other times during the day to maintain a 30 degree angle.
• Upright positioning during awake times in a way that doesn't compress the stomach. Front carrier pouches work well for small infants.
• Simple supports in infant seats and car seats that prevent "slouching over" that causes abdominal compression during and after feedings.

Timing of Feedings

Infants who receive large volumes at one time seem to be at higher risk of GER. Smaller, more frequent feeds may be helpful.

Thickened Feedings

While the addition of cereal to infant feedings to thicken them and reduce episodes of reflux has been a traditional approach to this problem, this approach to the treatment of GER is controversial.

• The use of feedings thickened with cereal may reduce the episodes of regurgitant reflux but non-regurgitant reflux and attendant problems may still occur. In fact, respiratory symptoms associated with GER may be worsened by the addition of cereal to infant bottles. Orenstein et al. (1992) found increased cough in infants with respiratory disease who were given thickened feedings. The addition of cereal to formula feedings may decrease gastric emptying time and actually increase episodes of reflux and aspiration.
• Thickened feeds are contraindicated for infants with weak sucking skills or uncoordinated feeding skills. These infants may experience decreased fluid or formula intakes when cereal is added to the bottle, and overall nutrient intake may be compromised.
• This intervention is not available to those who are breastfeeding at the breast.
• Nevertheless, many parents report that adding cereal to infant feedings is effective. For some infants a closely monitored clinical trial of thickened feeds may be appropriate. One approach might be to start with the addition of one level tablespoon of commercial infant oatmeal per two ounces of formula or expressed breast milk. Some infants will have difficulty nippling thickened feeds, and adequacy of fluid intake should be assessed. In general, infants should be closely monitored for efficacy and adverse outcomes.

Medications:

• Agents to change GI motility (prokinetic agents), which increase the rate of gastric emptying and raises lower esophageal sphincter pressure, may be prescribed.
• Agents to decrease acid production such as H₂ blockers, ranitidine (Zantac) and cimetidine (Tagamet), or proton pump inhibitors such as omeprazole are commonly prescribed for GER.
• Agents to protect gastric mucosa from damage by acid and pepsin such as sucralfate are not as commonly prescribed, but may be useful for some infants.

Surgical Management

Surgery is usually reserved for only the most difficult cases of well-documented GER that is accompanied by serious effects. There are several surgical procedures that may be used. The goal of surgery is to tighten the lower esophageal sphincter so that stomach contents cannot easily enter the esophagus. The immediate and long term results of GER surgery are variable.

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