Gastro-esophageal reflux disease
Gastro-esophageal reflux (GER) is the passage of gastric contents into
the esophagus, with or without regurgitation and vomiting. North
American Society for Pediatric Gastroenterology, Hepatology, and
Nutrition (NASPGHAN) and ESPGHAN defined pediatric gastro-esophageal
reflux disease (GERD) as GER leads to troublesome symptoms which affect
daily functioning and/or complications, such as hematemesis, dysphagia,
erosive esophagitis, poor weight gain, feeding refusal, dystonic neck
posturing, apnea, recurrent aspiration pneumonia, coughing or choking at
the end of feeding in infants and children. The children who had
specific underlying conditions such as neurolgical disease, pulmonary
disease (e.g., cystic fibrosis), congenital gastrointestinal
abnormalities (e.g.,diaphragmatic hernia, esophageal atresia, intestinal
atresia.), obesity or prematurity are more vulnerable for
GERD34. Lower esophageal sphincter (LES), angle of His
(angle between the esophagus and the gastric fundus), the crural
diaphgram and phrenoesophageal ligament are the components of the
anti-reflux barrier. The LES relaxes during swallowing and allows the
pass of esophageal contents to the stomach. The postprandial gastric
distension triggers transient LES relaxations (TLESRs) and the gastric
contents move upward into the esophagus. Despite TLESRs are considered
to be the major cause of GER episodes, delayed gastric emptying,
decreased LES pressure, increase in the His angle, increased
intraabdominal pressure may lead GER. Coughing, straining, increased
respiratory effort, medications, obesity, lying on right side position
may cause GER due to anti-reflux barrier
impairement35-38.
In the study of mechanical ventilated critically ill patients, the basal
LES pressure was found to be low and a minimal increase in abdominal
pressure due to such as suctioning, straining, coughing may cause
frequent reflux episodes. Also medications like anti-cholinergic drugs,
calcium canal blockers, barbiturates may relax LES39.
Enteral nutrition related gastric distension or delayed gastric emptying
may increase the frequency of TLESRs and causes increased GER episodes
in these patients31. Newton M et
al40. reported that GERD was diagnosed in 20% of the
children with tracheostomy and of these children 12.4% had tracheostomy
related complications, with odds ratio of 1.5 for developing
tracheostomy related complications. Ertuğrul A et
al41. demonstrated GERD was the major co-morbidity
(%28) in children dependent HIMV, most of them had an underlying a
neuromuscular disease. In the study of Blanchi ET et
al.42, the prevalence of reflux in the adults with
tracheostomy was reported as 45.2% and there was no typical symptoms
most of 24-hour pHmetry and manometry measurement.
In the presence of the GERD related symptoms in infants and children
with MV, red flag symptom and signs should be investigated (Table 6). In
the presence of these findings the appropriate tests and radiologic
evaluation should be performed to rule out other pathological conditions
(Table 7)34-38.
The treatment of GERD in otherwise healthy infants and children were
detailed in ESPGHAN and NASPGHAN recommendations34. In
suspicion of GERD and if there is no red flag symptom and/or signs, the
first step in treatment should be feeding modification. The head
elevation and positioning is not recommended in sleeping infants due to
the risk of sudden infant death syndrome34, but there
is no clear data for the infants with tracheostomy.
The nutritional interventions should be made according to patients
underlying illness, concomitant symptoms or disorders, age and
nutritional status. Food thickeners may be given to orally feeding
patients. Reducing feeding volumes, increasing feeding frequency and
avoiding overfeeding may relief the symptoms. If the infant fails to
these modifications, an extensively hydrolyzed protein-based formula and
in breastfed infants elimination of cow’s milk from maternal diet should
be considered for 2- to 4-weeks. If there is no response to extensively
hydrolyzed protein based formula, an amino-acid based formula may be
given. In children with NI who fed with tube whey based formula may be
given, it also help to gastric emptying. If there is no improvement,
acid suppression treatment should be considered for 4-8 weeks. The use
of alginates may slightly improve the GERD symptoms and signs but
ESPGHAN and NASPGHAN do not recommend use antacids/alginates for chronic
treatment of infants and children with GERD. Also proton pump inhibitors
(PPIs) may be considered in the treatment. If the symptoms improve in
4-8 weeks period, PPIs can be ceased6,34-38.
If there is no response to the optimal medical treatment in 4-8 weeks
(refractory GERD) or weaning attempts of PPIs are failed within 6-12
months period, possible underlying conditions which may lead to GERD
symptoms and efficacy of treatment (e.g., drug usage, dosage, adherence,
interactions) should be evaluated.
In suspect of congenital gastrointestinal abnormalities such as hiatal
hernia, pyloric stenosis, malrotation, duodenal or antral web, duodenal
or esophageal stenosis, or esophageal stricture, achalasia, extrinsic
compression of esophagus barium/water soluble radiopaque swallowing
follow-through studies should be performed. Abdominal ultrasound also
may be helpful to detect the congenital abnormalities. Follow-through
studies and abdominal ultrasound is not recommended to diagnose
GERD34-38.
In the suspicion of GERD due to persistent troublesome symptoms, the
association of the symptoms and gastroesophageal reflux events (both
acid and non-acid) should be identified by pH-multichannel intra-luminal
impedance (MII). If it is not available only pH-metry can demonstrate
the relation of symptoms only with acid GER events.
Esophagogastroduodenoscopy with biopsies should be performed to clarify
the etiology of esophagitis (ie, eosinophilic esophagitis) or identify a
mucosal disease as a complication of the GERD such as erosive
esophagitis and Barrett esophagitis34-38.
In the presence of reflux-related erosive esophagitis in infants and
children, the first-line treatment is proton pump inhibitors (PPIs). If
PPIs are not available histamine-2 receptor antagonists (H2RAs) may be
used. Baclofen may be considered before surgery in refractory GERD.
Kawai et al43. reported a decrease in vomiting, number
of acid refluxes with the gamma-aminobutyric acid type B receptor
agonist baclofen. The use of domperidon, metoclopramide or any other
prokinetics (e.g.,,erythromycin) in infants and children with GERD is
not recommended34.
Since the incidence of GERD in neurologically impaired children is high
(up to 70%) for these clinically fragile patients, ESPGHAN recommended
using whey-based formulas, thickening the enteral formulas, and PPIs
treatment before diagnostic tests.. Despite GERD symptoms cannot be
expressed by severely neurologically impaired patients, objective
diagnostic tests such as esophageal pH-metry or pH/multichannel
intraluminal impedance monitoring, and/or upper GI endoscopy will be
benefical to determine the futher need of PPIs
treatment6,34.
In the treatment of infants and children with GERD who are refractory to
optimal medical treatment, transpyloric or jejunal feedings may be an
alternative treatment to fundoplication, but there is no strong
evidence. In neurologically impaired children both procedures didn’t
prevent aspiration pneumonia. This condition may be independent of the
reflux events and related to their swallowing
dysfunction34,44. The complication rates of
transpyloric or jejunal feeding reported to be considerably high about
85%; including clogging, dislodgement, intussusception, and
perforation45,46.
Anti-reflux surgery is recommended as foloows; life threatening
complication under optimal medical treatment, refractory GERD symptoms,
underlying a chronic condition (e.g.,neurologically impaired, cystic
fibrosis), need for chronic pharmacotherapy to control the signs and/or
symptoms of GERD. Fundoplication leads to decrease the baseline pressure
of LES, the number of TLESRs and increase the length of intra-abdominal
esophagus. Despite different anti-reflux surgical procedures, Nissen
fundoplication is accepted as gold standart technique, with shorter
hospital stay and low incidence of perioperative complications and also
morbidity. Unfortunately, no reduction of extraesophageal symptoms such
as pneumonia and mechanical ventilation requirement was demonstrated in
neurological impaired children after
fundiplication44,47,48. Also, more than 75% of the
patients couldn’t cease acid suppression medications for at least one
year after fundoplication49. After
fundoplication gas-bloat, early satiety or pain after feeding,
dysphagia, retching, worsening aspiration risk from esophageal stasis,
unwrapping and redo fundoplication (2.2%-12.2%) are the other reported
side effects50,51.
Total esophagogastric disconnection may be considered as a rescue
procedure for neurologically impaired children with a failed
fundoplication Since these complications may inversly effect the
patients with tracheostomy, the parents should be carefully informed for
the risks and benefits of the surgical
interventions34.