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Los Altos Feeding Clinic
2235 Grant Rd Suite #2
Los Altos, California 94024
Tel: (650) 237-9111
FAX: (650) 396-7575
Email
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What
is Reflux?
Reflux,
or gastroesophageal reflux (GER), occurs when the contents
of the stomach pass back up through the Lower Esophageal
Sphincter (LES) into the esophagus. This refluxed liquid
contains food, stomach acid, enzymes, which help digest
protein, and may contain bile. The most harmful component
of the refluxed liquid is the stomach acid, which can
damage the esophagus. Up to one third of babies have
reflux at some time, but almost all outgrow it within
one year.
What
is Gastroesophageal Reflux Disease (GERD)?
Gastroesophageal
Reflux Disease is a more serious form of reflux. With
GERD the refluxed liquids can come completely up the
esophagus and out of the mouth (vomiting or spitting
up), or into the sinuses, or even into the lungs (aspiration).
With
GERD, reflux occurs more frequently and can be much
more painful than with GER. Repeated exposure to stomach
acid can cause the esophagus to become red and irritated
(esophagitis), and in severe cases can cause bleeding
and scarring of the esophagus, which can make swallowing
painful and difficult. Repeated vomiting can also damage
teeth enamel.
In
children, the pain of reflux often leads to food refusal,
lack of proper nutrition, no weight gain, weight loss
or failure to thrive, resulting in severe cases to the
need for g-tube or ng-tube feeding.
Another
very serious implication of reflux is if refluxed liquid
enters the lungs, potentially causing breathing problems
or pneumonia. If the refluxed liquid enters the sinuses
it can cause sinus infections and swollen adenoids.
In babies with reflux choking or apnea may occur.
Symptoms
of Reflux in Children
When
refluxed liquids enter the esophagus the acid begins
to damage the esophagus causing pain when swallowing,
called dysphagia, and inconsolable crying. Repeated
scarring of the esophagus may result in a narrowing
and hardening of the esophagus, or strictures, which
may cause food to become stuck in the esophagus.
When
the acid comes up to the throat the throat can become
hoarse and laryngitis may occur. Babies may spit up
frequently, spit up long after meals, and continue to
spit up even as they grow older.
Because
eating can be painful, children may refuse food or accept
only a few bites of food during a meal. Other children
may vomit frequently, even at every meal. Because they
may not eat enough, children with reflux might not have
adequate nutrition and may lose or stop gaining weight.
In some cases the child may stop growing for a long
period of time or may lose so much weight that they
fall below the average range of growth for their age,
in which case they may be labeled Failure to Thrive
by their pediatrician.
Reflux
occurs more often when lying down, so the child may
have trouble sleeping, may wake up frequently or may
cry when placed on a flat surface such as in a crib
after a meal. Sleep apnea may occur if refluxed liquids
block the air passage during sleep.
In
some cases refluxed liquids may travel up through the
esophagus and into the lungs, called aspiration. If
aspiration occurs the refluxed liquids in the lungs
may cause infections, coughing, wheezing, recurrent
pneumonia, sinus infections and asthma.
Causes
of Reflux
The
main cause of reflux is a malfunction of the Lower Esophageal
Sphincter (LES). Normally, the LES opens during swallowing
and then closes to keep the stomach contents in the
stomach. With reflux, however, the LES opens at times
not related to swallowing, or stays open when swallowing
is complete allowing the stomach contents to travel
up into the esophagus. In other cases the contractions
of the esophagus, which normally travel from the mouth
to the stomach, occur erratically, stop before the food
reaches the stomach, or don’t occur with swallowing.
Reflux
can also occur if the LES is weak and does not close
completely. In other cases reflux may occur because
the stomach is emptying slowly, causing more pressure
to be exerted against the LES and may make the contractions
of the esophagus stronger. Slow emptying of the stomach
may occur due to a malfunction of the GastroEsophageal
Valve (GEV).
Diagnosis
of Reflux
1. Barium Swallow Study
In a barium swallow study, also known as fluoroscopy,
the child drinks a chalky liquid, which shows up on
an x-ray. The x-ray can show places in which damage
to the esophagus becomes scar tissue, making a narrow
passage for food to pass. The x-rays can also show deformities
of the upper digestive tract.
2. 24-hour pH Probe
This is the most reliable test for reflux. A thin tube
is fed through the nose and placed in the esophagus
where the stomach and esophagus meet. The tube measures
acid levels over the course of 24-hours. If acid levels
are consistently high, reflux is occurring. Also, this
test can show if high acid levels occur when the child
cries, coughs or shows other symptoms of reflux.
3. Endoscopy
A small, flexible tube with a camera is fed through
the mouth into the esophagus and stomach, so the doctor
can see the lining of the esophagus and look for damage
that may be caused by reflux. Biopsies of the esophagus,
stomach and upper small intestines can also be taken
through the scope.
4. Milk Scan
A milk scan, also known as scintigraphy, measures how
quickly the stomach empties. The child swallows milk
mixed with a radium-labeled powder, which can be followed
through the digestive tract. This test can also show
if aspiration is occurring.
Breastfeeding
and Reflux
Breastfeeding
seem to provide some relief from reflux in infants.
This could be because it can be soothing to be breastfed.
Also, breastmilk is more quickly and easily digested
than formula. In particular formulas made from cows
milk can be hard to digest. And for babies with slow-emptying
stomachs, quick digestion can decrease reflux episodes.
Plus breastmilk may have some antacid qualitites, reducing
acidity in the esophagus or at least washing stomach
acid back into the stomach, thereby decreasing pain.
Treatment
of Reflux
1. Lifestyle
Changes
The vast majority of children eventually outgrow reflux,
usually within their first year of life. For these children,
lifestyle changes can be effective in increasing food
intake and reducing symptoms, such as crying and pain.
- Certain
foods, such as spicy, fatty or acidic foods may increase
reflux, so they can be avoided.
- Burping
the baby frequently and giving smaller, more frequent
meals may also help.
- Thickening
food or formula with rice cereal or oatmeal cereal,
which may be easier for a baby to digest than rice
cereal, may keep the food from being regurgitated.
- Gravity
can also help keep the stomach contents in the stomach.
Keeping the baby upright after meals by elevating
the head of the bed or crib with wooden blocks or
using a wedge, or having the baby sit in a bouncy
seat or infant carrier, can use gravity to help keep
food down.
- It
can also be a good idea to have the child checked
for allergies, which might be making the reflux more
severe.
2.
Medications for Reflux
When these lifestyle changes are not sufficient in combating
reflux, the child’s doctor may prescribe medications
to help alleviate symptoms.
- Proton
Pump Inhibitors (PPIs)
- Decrease stomach acid production, which can protect
the esophagus from damage from stomach acid
-
Should be taken one hour before a meal, so the medication
is at its highest levels during the meal.
- Examples of PPIs include omeprazole (Prilosec),
lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole
(Protonix) and esomeprazole (Nexium).
- Antacids
-Increase pH of the stomach, neutralizing acid
- Although quick acting, antacids only last 30 minutes
or less, so they must be taken repeatedly throughout
the day, in particular right after a meal and again
two hours after a meal as stomach emptying slows.
- Calcium antacids may cause acid rebound
- Aluminum antacids may cause constipation
- Magnesium antacids may cause diarrhea
- Examples of antacids include Gaviscon and Tums.
- Histamine
(H2 receptor) antagonists
- Reduce acid production by blocking histamine receptors,
which stimulate acid production
- Should be taken 30 minutes after a meal to allow
the meal to be digested by the stomach acid
- Do not help esophagitis (painful inflammation and
redness of the esophagus)
- Because it comes in liquid form, which is easier
for a child to take, histamine antagonists may be
prescribed more often for children.
- Examples include cimetidine (Tagamet), ranitidine
(Zantac), nizatidine (Axid), and famotidine (Pepsid).
- Prokinetic
agents
- Make the LES close more tightly, reducing reflux
- There is a possibility of adverse reactions to prokinetic
agents.
- Examples include metoclopramide (Reglan), cisapride
(Propulsid), erythromycin (Dispartab, Robimycin),
and bethanechal (Duvoid, Urecholine).
- Pro-motility
medications
- Stimulate the muscles of the digestive tract, including
esophagus, stomach, small intestines and colon, but
may cause constipation
- The effects of the medication on the sphincter and
esophagus are small and not very effective.
- Motility
medications are often paired with other reflux medications.
- The medication is taken 30 minutes before a meal
and at bedtime.
- Examples include Urecholine and Regalin.
3.
Surgical Treatment for Reflux
(Nissen Fundoplication)
If a child does not outgrow reflux, and lifestyle changes
and medications are not effective, particularly when
the child is not gaining weight, a doctor may consider
a surgical alternative.
In
a Nissen Fundoplication, the top of the stomach is wrapped
around the esophagus, creating an artificial sphincter.
The strong stomach muscles can pinch closed the esophagus,
keeping the stomach contents from coming back up into
the esophagus. The operation may be completed laprascopically
with a small incision in the abdomen.
The
vast majority of patients have less reflux after a nissen,
but there can be complications. Food can get caught
in the artificial sphincter. The food may come down
on its own or it can be removed through endoscopy. In
other cases the surgery may cause oral aversion, leading
to weight loss.
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