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GASTRO-OESOPHAGEAL REFLUX

GASTRO-OESOPHAGEAL REFLUX. ANNE ASPIN 2010. Douglas (2005). Excessive crying 30% of infants to GP Increase GOR in babies who cry excessively Parents believe they have reflux. Key factors that impact on infant distress Feeding management Parental responsiveness Sensory nourishment

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GASTRO-OESOPHAGEAL REFLUX

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  1. GASTRO-OESOPHAGEAL REFLUX ANNE ASPIN 2010

  2. Douglas (2005) • Excessive crying • 30% of infants to GP • Increase GOR in babies who cry excessively • Parents believe they have reflux

  3. Key factors that impact on infant distress • Feeding management • Parental responsiveness • Sensory nourishment • Sleep management

  4. Feeding management • Frequent feeding • Breast or bottle feeding technique • Cows milk allergy

  5. Parent responsiveness • Response depends upon urgency of cry • Louder , high pitch scream – communication • Need prompt response to cues

  6. Sensory nourishment • Sling / harness • Walks • Massage • Bathing • Soft music

  7. Sleep management • Sleep routine, night, day, quiet time • 18.00hrs most increased reflux rythmn Dreizzan et al (1990)

  8. Effects of these responses • Decreased crying at less than 3-4 mths of age • Decreased incidence of GORD once they are older.

  9. Health promotion • Shenassa et al (2004) • Early prevention and health promotion in maternal smoking and infantile gastro intestinal dysregulation

  10. motilin • An amino acid hormone produced by the duodenum and jejunum mucosa • Released every 90 minutes when fasting • Vagal nerve stimulation increases the number and force of contraction • Difficulty with comforting a crying baby may be due to cycle of increased gut motility, continual crying and higher motilin levels

  11. Purpose of study • Infants exposed to cigarette smoke is linked to elevated blood motilin levels • Which is linked to increased risk of gastro-intestinal dysregulation including colic and acid reflux

  12. Method • Critical review • Epidemiology, Physiologic, Biological evidence • Smoking and colic • Smoking and motilin levels • Motilin and colic

  13. Results • Six studies • Results from five studies shows there is an association with maternal smoking and excessive crying and intestinal colic • Smoking is linked to increased plasma and intestinal motilin levels • Higher than average level of motilin are linked to increased colic

  14. A case for left lateral positioning • Tobin et al (1997) • Prone posture recommended for GOR but associated with SID

  15. STUDY • 24 infants > 4days, <5/12 with symptoms GOR studies 48hrs PH • Randomly assigned prone, supine, left or right lateral • 1st 24hrs horizontal then 30o head elevation

  16. Results • GOR significantly less in prone and left lateral position than supine and right lateral position • Conclusion for this study, elevation may not always be of value

  17. Carre (1960), Meyers et al (1982) • I would disagree. • Car seats, elevation of the head of the cot. • Risk of slumping- cause raised intra abdominal pressure and reflux • (Dodds et al 1981, Orenstein et al 1983, Jolley et al 1978

  18. Back to the drawing board • Effect of nursing in the head elevated tilt position (15 degree) on the incidence of bradycardia and hypoxaemia episodes in the preterm infant. (Jennie et al 1997)

  19. Method • 12 spontaneous breathing preterm infants with idiopathic recurrent apnoea studied in a randomized controlled crossover trial. • 24 hrs prone and horizontal • 24 hrs prone 15 degree tilt • Position changed 6 hourly randomly

  20. Result • Improved gastric emptying • Improved weight gain • Faster gastric emptying on tilt • No difference in gastric residuals • Some studies show increased apnoea with GOR, whereas others do not

  21. Are we seeing the light? • Ewar et al (1999) • Small sample- 18 preterm babies • Clinical symptoms of GOR • 24 hour lower oesophageal PH monitoring

  22. Positions • Prone for 8 hours • Left lateral for 8 hours • Right lateral for 8 hours • Result – prone and left lateral significantly reduce GOR, decrease in number of episodes and duration

  23. Case history • Ex 28/40, stoma for nec Full feeds, 1 kg, wt increasing, 28days old. Laid horizontal, supine, boundaries for comfort small vomit, increasing residuals. Chest infection.

  24. Case history • Term, gastroschisis, • 3 hrly feeds, possits, • irritable fussy, nurses say he appears hungry one hour after feeds, more food?

  25. Case history • Term baby, meconium ileus, end to end anastomosis • Full continuous feeds • Feeds changed to three hourly • Loose stools • Vomiting, sore buttocks • Put back to 2 hourly feeds

  26. Case history • TOF and OA, term, primary anastomosis • Full feeds, home • Disinterested in feeds • Pale, mucousy • Stricture • Effects on reflux episodes

  27. Preterm babies • Poets (2004) • GOR common in preterm infants (approx 3-5 episodes per hour) • Omari et al (2002) studied 36 infants, 14 symptomatic. GORD triggered by gastric distension and abdominothoracic straining

  28. Preterm babies • GOR doubled with ng tube in situ • GORD is not related to delayed gastric emptying so why use prokinetic?

  29. CMA Diarrhoea Bloody stools Rhinitis, nasal congestion Constipation Eczema/ dermatitis Lip swelling itching Dysphagia, haematemesis Melena Nausea, belching Arching, bradycardia Hiccups Aspiration, chest infection Stridor, laryngitis Cows milk allergy / GOR

  30. Salvatore and Vanderplas (2002) • Gastric emptying. • Multiple dietary factors- volume, calorie density, osmolarity, protein content all effect gastric motility

  31. Type of milk regulates gastric emptying rate, • And gastric residual content • Salvatore and Vanderplas (2002) reports delayed gastric emptying with GORD by causing inappropriate relaxation of the lower oesophageal sphincter

  32. Constipation • Formula milk associated with constipation where overfeeding occurs. • Motility disturbance

  33. Anti-reflux procedure • Sullivan (1999) • 15% - 75% neurologically impaired • Gastric dysrythmia • Persistant activationof emetic reflex • Gastrostomy feeds are efficient and cost effective • 26% complications, GOR secondary to PEG placement.

  34. Nissans Fundoplication • Relieves symptoms in more than 80% patients • Pearl et al (1990), 234 patients • 153 disabled • Post op complications 26% NI, 12% others • Re operation 19%, 5%

  35. Fankalsrud et al (1998) • Retrospective study 7467 patients, 7 large children hospital • 56% neurologically normal • 44% neurologically impaired • 40% < 1 year old • Good results 95% NN, 84% NI • 4.2% complications as opposed to 12.8%

  36. So what are we saying? • Nurse baby left lateral • Small regular feeds • Observe behaviour • Measure and monitor residuals • Crying one hour after feeds may indicate GOR • Head tilt at risk infants

  37. Position • The jury remains out on many aspects • Caution when critique literature • Treat each baby as individual

  38. That is all for now Thank you for listening

  39. References • Douglas P (2005). Excessive Crying and Gastro-Oesophageal Reflux Disease in Infants : Misalignment of Biology and Culture. Medical Hypotheses. Vol 64,Issue 5, Pg 887-898 • Ewer A, James M, Tobin J (1999). Prone and Left lateral Positioning Reduce Gastro-Oesophageal Reflux in Preterm Infants. Archives of Disease inChildhood. 81 : F201 - F205 • Fonkalsrud E, Ashcraft K, Coran A, Ellis D, Grosfield J, Tunell W, Weber T (1998). Surgical Treatment of Gastroesophageal Reflux in Children: • A Combined Hospital Study of 7467 Patients. Paediatrics. Vol 101, No. 3 • Huang R-C, Forbes DA, Davies MW (2005). Feed Thickener for Newborn Infants with Gastro-Oesophageal Reflux (Review). The Cochrane Collaboration.Issue 2

  40. References cont. • Jenni O, Siebenthal K, Wolf M, Keel M, Duc G and Bucher H (1997). Effect of Nursing in the head Elevated Tilt Positon (15º) on the Incidence of Bradycardic and Hypoxemic Episodes in Preterm Infants. Paediatrics. 100 : 622-625 • Nelson S, Chen E, Syniar G, Kaufer Christoffel K (1998). One-Year Follow-up of Symptoms of Gastroesophageal Reflux During Infancy. Paediatrics. 102:67 • Omarj T, Barnett C, Benninga M, Lontis R, Goodchild L, Haslam R, • Dent J, Davidson G. Mechanisms of Gastro-oesophageal Reflux in Preterm and Term Infants with Reflux Disease. Gut:51 ; 475-479 • Peter C, Sprodowski N, Bohnhorst B, Silny J, Poets C (2002). Gastroesophageal Reflux and Apnea of Prematurity: No Temporal Relationship. Paediatrics.109 : 8 - 11 • Philips B (Ed) (2002). Towards Evidence Based Medicine for Paediatricians. • Archives of Disease in Childhood. B6:77-81 • Poets C (2004). Gastroesophageal Reflux: A Critical Review of Its Role In Preterm Infants. Paediatrics. 113 : 128-132

  41. References cont. • Salvatore S, Vandenplas Y (2002). Gastroesophageal Reflux and Cow Milk Allergy: Is There a Link? Paediatrics. Vol. 110 • Shenassa E, Brown M. Maternal Smoking and Infantile Gastrointestinal Dysregulation : The Case of Colic. Paediatrics. Vol. 114 No. 4 October 2004 • Sullivan P (1999). Gastrostomy feeding in the disabled child : when is an anti-reflux procedure required? Archives of Disease in Childhood. 81; 463-464 • Tighe M and Beattie R (2010). Managing gastro-oesophageal reflux in infancy. Archives of Disease in Childhood. 95 : 243 - 244 • Tobin J, McCloud P, Cameron D (1997). Posture and Gastro-oesophageal Reflux: A Case for Left Lateral Positioning. Archives of Disease in Childhood. 76 : 254-258 • Wenzi T, Schneider S, Scheele F, Silny J, Heimann G, Skopnik H (2003). Effects of Thickened Feeding on Gastroesophageal Reflux in Infants: A Placebo-Controlled Crossover Study Using Intraluminal Impedance. Paediatrics.111: 355 - 359

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