Imaging for reflux is
almost always a bad idea,
and the reason I say that is because
it’s almost always present.
Remember, 60% of totally normal newborns
regurgitate at least once a day.
When we do a swallow study, which
is what you can see on this slide,
we make children NPO for a period of time
and then send them to the radiology suite.
They greedily eat down their contrast
because they’re very hungry,
and then a lot of the
time, reflux is seen.
That doesn’t mean the
child has reflux disease.
The false positive rate is high
because reflux is physiologic.
So, diagnosis of this condition
is actually somewhat clinical.
If we suspect reflux disease,
we don’t often test for it
but rather we’ll treat it empirically
and see how the child responds.
Imaging is really only for
suspected swallowing problems
in children with neurologic deficit, for
example, where we suspect a problem,
or in children where there might
be something structurally
preventing the esophagus from
working such as a vascular ring.
Upper GI series will rule out
but again, there’s a very high
false positive rate for reflux.
We could do nuclear scintigraphy.
This is a radio-labeled food,
and then we see whether it goes
to the stomach or the lungs.
This is useful really for things
like delayed gastric emptying.
We don’t use this test very often.
So, the test of choice, if you must do
one, is the esophageal impedance probe.
What this does is it’s a
tube, as in this child,
where it goes into the nose
and down into the esophagus.
There are lots of little measuring
devices that are looking for measuring
electrical impedance between
these little measuring things
all the way down the probe.
So, when the patient refluxes and electrical
conducting fluid now goes over these,
you can tell exactly what
level that fluid has gone to,
and therefore determine the distance that
the esophagus is having reflux climb up it.
This has replaced the pH probe,
which could only detect acid.
This detects all types of fluid.
So, for infants who were already being
treated with omeprazole, for example,
you will still detect an
abnormal impedance probe
but you would not necessarily
have an abnormal pH probe.
This correlates non-specific
symptoms with GER events.
So for example, if a child has
apnea, stridor, and irritability
while the pH probe was going up, that
implies that there’s a connection here.
So the mother or the parent
can have a button to press
while the child is sitting
there on this study
and they can correlate the
button with the event of reflux
and see if there’s a correlation,
and that can help them determine
if the reflux is the problem or if that’s
just what the parent is concerned about,
and this baby is
actually doing normally.
To truly diagnose it, we can
also do endoscopy and biopsy,
which is a reliable diagnostic
method but is invasive.
We have to put the child to sleep, put a
camera down there and look for erosions.
It’s usually unnecessary, unless there’s
a suspicion for another problem
and then we happen to find
an evidence of reflux.
So there are some nonsurgical
therapies that we can do for reflux.
First off, we can educate
about feeding large volumes.
If infants eat smaller volumes more
frequently, they’re less likely to reflux.
Large volumes are likely to fill up the
stomach and are more likely to reflux.
Positioning upright after feeds
may well be on your exam
but actually has been shown
not to be effective.
Positioning after feeds
really is of no benefit,
and in fact, some people recommend
sitting in a car-seat after feeds,
but that’s actually been shown
to increase aspiration risk.
So that is not warranted.
If we decide to treat in a medical fashion,
there are two ways we can go about it.
One is to suppress acid
production in the stomach,
and this will reduce pain and
fussiness with refluxing events.
However, it does not
prevent the reflux itself.
It’s not acting as a barrier, it’s
just reducing the amount of acid.
And the problem is it turns out
that refluxing is good for you.
Yeah, I said that.
Refluxing is good for you.
In infants and in adults,
the refluxing of acid up into
the upper area of the throat
causes a reduction in the amount
of bacteria that are there
and reduces the
risk of pneumonia.
Children and adults on
acid suppression therapy
have an approximately six-fold
increase risk for pneumonia.
They also are at risk for gastroenteritis.
And in adults, C. diff enteritis.
So, it’s not totally benign
to start acid suppression.
An alternative in infants
is to thicken their feeds.
Viscous feeds are
less likely to reflux
simply because it’s harder to
get them back up the tube.
This is more effective than
acid suppression in most cases.
It does actually prevent the refluxate.
However, it can cause obesity.
So, infants were fed thickened
feeds will gain weight much faster
because the thickener is caloric addition.
And as we have learned, rapid weight
gain in the first year of life
puts children at risk quite remarkably for
adult type 2 diabetes much later in life.
So it is not a benign thing
to cause a baby to gain rapid weight
during their first year of life.
There is a surgical alternative that is in
existence for children with severe reflux,
and often, this is limited to children
who are either getting a G tube
because they’re incapable of eating,
and especially we see this
done in children with
severe cerebral palsy or
other neurologic problems.
This is called the Nissen fundoplication,
and basically, it’s a surgical wrap of the
gastric antrum around the distal esophagus.
This is reserved for chronic
gastroesophageal reflux disease,
which is not responsive
to other therapies.
The problem is that when we finally studied
in the one largest and best study we did,
it turns out that children
who had this procedure done
did not actually have
improved outcomes in terms of
for reflux-like events.
So, it’s not totally clear that this
operation, while it’s commonly done,
is particularly effective.
But sometimes, there’s not
much else you can do.
That’s all I have for you today about
gastroesophageal reflux disease
and the other problems that are
structural involving the enteric system.
Thanks very much.