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December Newsletter & Notes From Nancy
Hello! I hope that you all had a Happy
Thanksgiving! This has been a very busy and exciting month for me.
I now need to ask for your help. The filing
fees for IARP are going to add up to around $500 and I can't pay these fees all by myself.
Paul has told me that any donations we receive will be tax deductible for the
donator since we are pending tax exempt. If you can give a little bit, please do to
help me continue this web site and do even more to help support you and parents like you.
Contact me if you would like to make a donation. Email: Nancy
I've run across some very interesting articles
this month and have included them here.
Have a very Merry Christmas and safe New Year!
I'll write you again in 1999!
Love, Nancy
Founder, International Association of
Reflux Parents & Refluxmoms Mailing list
To go to newsletters from previous months, click here: November
Newsletter
1: Eosinophilic Gastroenteritis, discussed.
2: Management of GERD
3: HOPKINS RESEARCHERS EXPLORE NEW WAYS TO TREAT CHILDREN'S REFLUX
4: An Interesting Email that I received, perhaps worth investigation?
1: Eosinophilic Gastroenteritis:
- Clinical:
The condition may be related to an allergic or immunologic cause as symptoms tend to
follow ingestion of certain foods and affected patients tend to have history of food
allergy. In this condition there is extensive infiltration of one or all layers (mucosa,
submucosa, muscular layers, and serosa) of the stomach and/or small bowel by eosinophils.
Symptoms include epigastric pain, vomiting, and diarrhea. Patients also develop a protein
losing enteropathy due to increased mucosal permeability which results in hypoalbuminemia
and hypo-gammaglobulinemia. Peripheral eosinophilia is found in 60% of cases. The disease
is generally self-limited with spontaneous remission. Treatment consists of steroids and
removal of sensitizing agent.
- X-ray:
On UGI acutely there are diffusely enlarged folds, typically limited to the distal
stomach, but the duodenum and small bowel are also involved in 50% of cases. There is a
characteristic 'saw tooth' appearance to the small bowel, especially the jejunum. The
bowel is typically rigid, but returns to normal following therapy. Multiple nodules may be
seen if there is predominantly submucosal infiltration. Chronically, the antrum becomes
contracted with a cobblestone appearance. There is a narrowed, nodular pylorus and antrum
(distal stomach) with duodenal extension.
2: Teaching Files:
Management of Gastro-Esophageal Reflux (GER) in Newborns
Rationale Document for CSMC Clinical Guideline 95-242-G.
Prepared by Peggy Ordonez, RN, NNP, Cedars-Sinai Medical Center, Los Angeles, California.
------------------------------------------------------------------------
Incidence and Definition
GER, or the backward flow of gastric contents into the esophagus, may occur as a single
event or as a chronic condition. In infants, it may be physiologic or present with
pathologic symptoms. Reflux disease in older children, once established tends to persist,
whereas reflux in infants generally resolves during the first year of life with or without
treatment (Carre, IJ, 1979; Shepherd, RW,Wren, J, Evans, S, et al, 1987). The spitting up
of normal newborns that accompanies burping is a common event identified to parents as
part of newborn care, and is a normal process. It has been suggested that a smaller ratio
of esophageal to gastric volume may be responsible for this (Orenstein, SR, 1991).
The ability to quantify how many episodes of reflux in a given time frame is normal for
infants has been fraught with difficulties and controversy. Mainly the difficulty deals
with the diagnostic testing for reflux, for which the gold standard is pH probe
monitoring. Since the staple diet of an infant is milk, this provides a buffer and it
makes it impossible to detect changes in pH unless the stomach has emptied. Use of apple
juice with its acidic pH has been practiced, but the results cannot be reliably applied to
formula, as the esophagus probably does not process the two solutions in the same manner.
There are some norms that have been published based on age that report means in percentage
of recorded time spent with pH equal to or less than 4, and also number of reflux episodes
lasting longer than 5 minutes (Orenstein, SR 1991). Symptomatic reflux, however, can be
quantified and evaluated. In a study reported by Hrabovsky & Mullett, 1986, they
reported the incidence in their preterm population as 2.8% (22 cases out of 760
admissions). The current literature does not offer any other citations of percentage of
occurences in the preterm population.
In general, reflux can be divided into physiologic, symptomatic or pathologic. Physiologic
GER describes the normal newborn infant who spits up with burps, continues to feed well,
grows well and thrives. Symptomatic reflux includes those infants who have some spectrum
of observable events that occur that lead one to suspect GER is present. Symptoms include
frequent vomiting (> 2 times a day for more than 2 days), which may be effortless
drooling of formula from the mouth or projectile vomiting, increasing tracheal secretions,
hypoxia or desaturations, recurrent episodes of pneumonia, stridor, recurrent cough or
wheezing, apneic and/or bradycardic episodes, and irritability with feeding (Dalt,
Mazzoleni, Montini, et al, 1989, Orenstein, 1991). Pathologic reflux is significant enough
that it produces a detrimental physical change, such as poor weight gain, mucosal
ulceration, or chronic respiratory symptoms not due to known causes.
Pathophysiology
The esophagus is a muscular tube lined with squamous epithelium and separated from the
pharynx above and the stomach below by tonically closed sphincters. Its main function is
to convey ingested material from the mouth to the stomach. The sphincters must open many
times a day to allow swallowed material into the stomach, to vent swallowed air and to
allow the occassional regurgitation of noxious gastric material. In the adult, physiologic
reflux episodes are brief and occur approximately 5 times in the postprandial hour; their
frequency decreases rapidly to a baseline of close to zero about 1 or 2 hours post
prandially (Jolley, Herbst, Johnson, et al, 1981). Based on research reported by Dalt and
group, 1989, asymptomatic infants reflux about 24 times in 24 hours. Mean time spent
refluxing was 1.3%. Pediatric radiologists consider an upper GI to be significant for
reflux if there are more than 2 episodes of reflux in a 5 minute period.
Pathologic reflux occurs when the reflux events increase in frequency or duration, when
the refluxed material is not cleared from the esophagus, when the refluxed material is
regurgitated and caloric loss ensues, or when the refluxate is noxious to the esophageal
mucosa and causes esophagitis. Factors that contribute to GER disease in infants include,
but are not limited to:
•limited gastric volume and delayed gastric emptying time;
•increases in gastric pressure due to abdominal breathing;
•transient lower esophageal sphincter relaxations;
•gravitational effects due to positioning;
•upper esophageal sphincter dysfunction/ uncoordination; and
•drugs that are commonly used in newborns that decrease lower esophageal sphincter
tone.
GER may produce pathologic states including:
•esophagitis leading to mucosal ulceration, strictures, vomiting and poor feeding;
•aspiration pneumonia;
•stridor or wheezing from reactive airways;
•obstructive apnea and bradycardia; and
•increased risk of sudden infant death.
Diagnosis
The diagnosis of GER may be made based on a combination of clinical symptoms and history
plus diagnostic work up. Diagnostic tests include:
Extended pH probe monitoring: This is considered the gold standard for diagnosis
(Orenstein, 1991). Recent research literature cites pH monitoring as 100% sensitive and
94% specific (Dalt, 1989). 24 hour monitoring is felt to be necessary to establish an
accurate record. Definition of a reflux episode varies from a drop in pH less than or
equal to 4 lasting at least 8 seconds (Dalt, 1989) to at least 15 seconds (Society
Statement of the Working Group of European Society of Pediatric Gastroenterology and
Nutrition, 1992).
The number of reflux episodes considered as normal has not been well established. A
descriptive study of 509 healthy full term babies who were being screened for risk of SIDS
because they were siblings of SIDS infants, has been published by Vandenplas et al, 1991
and presents data from 24 hour pH monitoring of these asymptomatic infants. This may be as
close as we can get to a good study of what is "normal" for physiologic reflux
in infants. 95% of these infants had a reflux index (percentage of total investigation
time with pH < 4) of 10, with 72 reflux episodes documented, 9 of which were longer
than 5 minutes duration, with the longest duration 41 minutes. This study also reports
some norms that are age related and may be helpful in the interpretation of pH probe
studies. What may be more important is the clinical events that occur when reflux happens.
Interpretation of pH probe results need to be considered with clinical symptoms and should
only be done by a certified pediatric gastroenterologist familiar with the infants
clinical history and symptoms.
Upper GI/Barium swallow: Important to obtain in infants who present with vomiting in order
to identify strictures, webs, pyloric stensosis, malrotations of UGI tract, or dysmotility
of upper esophageal sphincter. It may also identify severe esophagitis. This is also
necessary to perform when there is no clinical presentation of vomiting but diagnosis of
GER is made by pH probe study, in order to rule out an organic cause for the GER.
Technetium scintigraphy: This is useful for identifying refluxate that is nonacidic that a
pH probe would not be able to detect. Radiation exposure is less than with barium swallow.
However, sensitivity is reported to be 59-93% with differences being ascribed to
technique. Regurgitant reflux is frequently missed. Gastric emptying time can be
quantified, and an abnormal study is defined as more than 50% of marker retained in
stomach after 60 to 90 minutes (Fonkalsrud, Berquist, Vargas et al, 1987).
Endoscopy: This may be performed in infants greater than 2 kg. It is useful in diagnosing
esophagitis and may preclude the need to perform a pH probe study.
Esophageal manometry: Use is limited to infants with symptoms of esophageal dysmotility.
Three channel pneumocardiogram: For infants who present with symptoms of apnea, this study
combines pH probe with heart rate and breathing patterns.
Indications for GI Consult
1.To assist the primary care physician in clarifying whether GER is responsible for the
symptom in question. Examples would be apnea or recurrent aspiration.
2.Infant is believed to require an esophageal pH probe.
3.Reflux not responsive to the medical management of the attending physician.
4.Anatomic abnormality of the GI tract.
5.Fundoplication is contemplated.
6.GI tract bleeding is present.
Management
Conservative medical management refers to attention to positioning, thickened feedings and
small volume feeds. Recent literature questions the efficacy of any of these measures, and
generally are performed on those infants with mild or suspected GER, who do not have any
pathologic disease.
Pharmacologic therapy is added once diagnostic work up supports the clinical diagnosis and
is usually in the form of a prokinetic agent such as metaclopramide and addition of an H2
blocker such as cimetadine or ranitidine if esophagitis is also suspected. Bethanecol has
respiratory side effects in infants with asthma and is usually not used in the premie NICU
population. Metaclopramide (Reglan) can cause central nervous system disturbances when
used in range of 0.3mg/kg/dose. It is recommended that Reglan be used at a starting range
of 0.1 mg/kg/dose every 6 hrs and may be increased to 0.2 mg/kg/dose. Doses of 0.3
mg/kg/dose have been safely tolerated but also known to cause some dyskinetic movements,
so need to be used with caution in the higher dose range. Cisapride is another prokinetic
drug that has the same side effects of Reglan and Bethanecol, but side effects are seen
less often. It is now available for use, but is not approved by the FDA as therapy for
GER. In the future, treatment with Cisapride may replace Reglan as clinical experience
with this drug increases. GI consult should be obtained if contemplating using this drug.
Medical management is appropriate in the infant with moderate reflux symptoms. Medical
therapy should be re evaluated after 2 months. Severe reflux symptoms which include
aspiration pneumonia, recurrent failures to remain extubated, significant apnea or
bradycardia, and poor weight gain, may benefit from surgical intervention. Publication of
data from Dalt, 1989, reports little success in medical management of GER in infants with
pH probe study results of > 20 episodes of reflux longer than 5 minutes or reflux time
> 27%. The procedure of choice is a Nissen fundoplication. There has been a high
incidence of delayed gastric emptying in infants needing fundoplication (Fonkalsrud,
1987), therefore, a technetium gastric emptying study or milk scan may be considered prior
to fundoplication in order to rule out the need for concurrent pyloroplasty.
Infants with dysmotility syndromes documented on cine swallow studies may benefit from
percutaneously placed gastrojejunal tubes rather than fundoplication (Albanes, 1992).
Please note that the North American Society for Pediatric Gastroenterology and Nutrition
is currently developing guidlines for management of GER, and once these are finalized,
this current document will be reviewed with respect to consider this group's
recommendations.
3: HOPKINS RESEARCHERS EXPLORE NEW WAYS TO TREAT CHILDREN'S REFLUX
November 8, 1995(Couldn't find anything on this that was more recent)
Johns Hopkins Children's Center researchers speculate that food allergies --
those not detected with standard tests -- might be the cause of some gastrointestinal
problems in children. If proven, their allergy theory could introduce new ways to evaluate
and treat kids for problems like severe nausea, pain, vomiting and poor weight gain.
Currently, these children receive medication to stop acid production and even surgery to
stop acid regurgitation. According to the study, however, acid reflux may not be the
problem at all and treatment may be as simple as restricting certain foods. The study
appears in the November issue of Gastroenterology.
"Previously, these children were tested for food allergies, but traditional skin
tests were negative," says Kevin Kelly, M.D., who directed the study when he was at
Hopkins. "When they didn't improve with common therapies, we tried to approach the
problem from a different perspective."
According to Kelly, biopsies of 10 patients revealed eosinophil cells in the esophagus, a
common sign of acid reflux.
"We originally thought that the eosinophils were present because of acid production
and reflux. Because of this study, we now think that they are the result of a
hypersensitive reaction to ingesting food proteins," he says.
To prove their theory, the researchers took away most foods and placed the children, ages
8 months to 12 years, on an amino-based formula for an average of 17 weeks. The formula is
free of the proteins that trigger allergic responses but provides adequate daily calories
with the proper distribution of carbohydrates, fats, vitamins, and minerals for growth.
In addition to the formula, patients were allowed clear liquids and foods made from apples
and corn, since children rarely are allergic to them.
During the trial, eight of 10 patients quickly became free of chronic gastrointestinal
complaints and two reported substantial improvement. Biopsies showed lower or no
eosinophils in all 10 patients.
To further support the allergic hypothesis, the patients were gradually reintroduced to
specific foods, such as milk, soy, wheat, peanuts, and eggs. The gastrointestinal symptoms
were recreated in 9 of the 10 patients, by one or more of these foods. When the
allergy-causing food was identified and eliminated, patients again improved. Eight of the
10 patients eventually stopped chronic anti-reflux medications.
Kelly says that although these amino-based formulas are reasonable tools to uncover
allergies, further studies need to be done to determine just how protein sources in the
diet interact with the gastrointestinal tract.
Kelly is now director of pediatric gastroenterology at St. Christopher's Hospital for
Children in Philadelphia.
Other Hopkins researchers involved in this study include: Jay Perman, M.D., professor of
pediatrics; Peter Rowe, M.D., associate professor of pediatrics; Hugh Sampson, M.D.,
professor of pediatrics; and John Yardley, M.D., professor of pathology. Audrey Lazenby,
M.D., a former Hopkins assistant professor of pathology, is now at the University of
Alabama at Birmingham.
Funding was provided by the National Institutes of Health, the National Institutes for
Allergy and Infectious Diseases, and Scientific Hospital Supplies, Inc. in Gaithersburg,
MD, who provided the formula. This study also was supported by Hopkins Pediatric Clinical
Research Unit.
4: Alternative Therapy for GERD--Perhaps worth some investigation?
I have been diagnosed with Gerd and have had this disorder for over a year
now.For the first 3 months I tried the losec and tagament methods of control, call me
cheap but who can afford the cost of these drugs.
I went to a new family doctor who also happens to be a herbalist. I asked him if there was
anything else I could do to control this disorder with out all the drugs. There is a way
and the reason I am emailing you is because I can not imagine being a small child and
having to live with this. I have been on FOOD therapy for 1 year now and have had NO
problems with any symptoms of pain. The food therapy method is very easy and affordable
since we all have to eat anyway, and it is for all ages.
My daily diet consists of 1 serving of Astro yogurt(has a high content of live bacteria) a
day.
For those people that can not stomach the thought of eating yogurt if you can buy this
brand do so, I have people who hate yogurt eating this stuff. You can also eat a couple of
fresh slices of pineapple after a meal
or papaya. If you don't like any of these foods than take digestive enzymes. You can buy
Papaya of Bromelien enzymes at most health food stores and you just have acouple of these
after a meal.
You must avoid all caffeine when you choose the food therapy method or you will still
suffer with the pain. Coffee, Cola's and to much chocolate are a big problem with this
type of therapy. I have shared
this method with several people with GERD and it seems to help others just as it has
helped me.
On another note I noticed that you listed antacids to cope with this problem and I have
found the only one that really will help is Gavascon.(NOTE:--DON'T KNOW IF IT"S OKAY
FOR PEDIATRIC USE) On their label it actually mentions GERD relief. I hope that you would
consider sharing this method with the thousands
of people that suffer with this disorder.
B. Reed
Alberta Canada
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