Gastroesophageal reflux in infants: a primary care perspective

This clinical paper discusses the role of the pediatric nurse in the evaluation and management of gastroesophageal reflux (GER) in infants. During an infant's first year of life, GER is a common occurrence and concern of families. The infant with uncomplicated GER may be managed conservatively with feeding schedule modifications, thickened feeds, changes in positioning, or a trial of formula change. Gastroesophageal reflux disease (GERD) is a pathological process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms or complications, and changes in neurobehavior. Management of the infant with GERD, in addition to non-pharmacological interventions, involves further diagnostic evaluation and pharmacologic therapy, depending upon the child's history and clinical presentation. While most cases of GER are self-limiting, complications include esophagitis, bronchospasm, apnea, aspiration pneumonia and other otolaryngologic disorders. The pediatric health care provider should offer an ongoing, comprehensive clinical approach to the family based on considerations of growth and development, and the quality of interactions between the caregivers and child.     

Clinical significance of 24-hour intraesophageal pH monitoring in GERD patients

24-hour intraesophageal pH monitoring(24-pH-M) is a method of choice to measure the esophageal acid exposure, and evaluate a patient's lifestyle who has reflux symptoms. The 24-pH-M is indicated to the cases who have at least one of the following signs/symptoms; endoscopy negative GERD(gastroesophageal reflux disease), atypical clinical course for reflux disease, atypical symptoms of GERD, and those who are subjected to have surgical treatment. In the 24-pH-M, not only the duration of gastroesophageal reflux(GER), but also reflux and symptom association should be evaluated. The 24-pH-M is useful to investigate the diagnosis and treatment of GERD including reflux esophagitis.     

Sleep apnea syndrome

The association between gastroesophageal reflux disease (GERD) and obstructive sleep apnea syndrome (OSAS) has recently been suggested. Patients with OSAS have a high frequency of nocturnal GER, and patients with GERD have various sleep-related symptom such as snoring and apnea. However, the causal relation between OSAS and GERD has not been sufficiently elucidated. The treatment of OSAS with nasal continuous positive airway pressure significantly reduces GERD symptom and nocturnal GER in both patients with and without OSAS. On the other hand, treatment of GERD in patients with OSAS improves the number of arousal during sleep, but one study showed a significant decline of apnea index. It is necessary to make further studies evaluating the association and treatment of OSAS and GERD.     

Pathophysiology of GERD: mechanisms of gastroesophageal reflux and prolonged esophageal acid exposure time

GERD is characterized by excessive esophageal acid exposure time. This suggests that either the rate of gastroesophageal reflux (GER) is higher and/or that the esophageal acid clearance time is longer. Transient LES relaxation (TLESR) is the single most common mechanism underlying GER in both normal subjects and patients with GERD. Whether or not the rate of TLESRs is higher in patients with GERD remains unclear. It is in the sitting or upright position that acid reflux mainly occurs, however, there seems to be no difference in the rate of TLESRs between both groups. The rate of TLESRs accompanied by acid reflux has been consistently shown to be significantly greater in patients with GERD than in normal subjects. Other mechanisms of reflux in patients with severe GERD are a hypotensive LES and ineffective esophageal motility which is found in severe GERD and which impairs bolus clearance of acid and thus increases acid contact time with the esophageal mucosa.     

咽异感症与胃食管反流的关系

目的 观察咽异感症患者的胃食管反流情况,评估胃食管反流在咽异感症病因学及临床表现中的作用.方法 按罗马Ⅱ标准,对26例咽异感症患者进行食管内24 h动态pH和胆汁监测,然后进行7 d的埃索美拉唑(耐信)试验治疗,并选择26例同期年龄、性别相匹配的胃食管反流病患者进行对照.结果 观察组发生病理性反流者咽异感症8例(30.8%),对照组17例(65.4%),两组比较差异有统计学意义(P＜0.05).埃索美拉唑治疗后咽异感症7例症状消失,10例症状减轻,有效率65.4%.对照组13例症状消失,9例症状减轻,有效率84.6%.两组比较差异无统计学意义(P＞0.05).结论 部分咽异感症患者存在病理性胃食管反流,用抑酸治疗有效,提示病理性胃食管反流可能是咽异感症的病因之一.     

An Antiregurgitation Milk Formula in the Management of Infants with Mild to Moderate Gastroesophageal Reflux

Background: Thickened milk formulas are used to treat infants with gastroesophageal reflux (GER), but these substances often increase the duration of reflux episodes and worsen symptoms, and they have been associated with diarrhea, constipation, and cough.Objectives: The aims of this study were to determine the efficacy of an antiregurgitation milk formula in the clinical and laboratory setting in infants with proved GER, to investigate any possible adverse events (cough and change in the number of bowel movements or the consistency of stools), and to identify its effects on height and body weight.Methods: Infants with recurrent vomiting and GER who were not responsive to standard treatment were eligible for the study. Infants in the treatment group (group A) were managed for 4 weeks with a specific antiregurgitation milk formula (with cornstarch and an increased amount of casein), and those in the control group (group B) were given a standard milk formula. The number of episodes of vomiting, regurgitation, and cough, as well as the frequency and consistency of stool, height, and body weight were noted at least 10 days before and during the study. A second pH monitoring was performed after 4 weeks in both groups.Results: Fifty-six infants (30 boys, 26 girls; mean [SD] age, 3.1 [1.2] months) were included in the study; 30.4% had mild GER; 44.6%, moderate GER; and 25.0%, severe GER. Significantly more infants in group A than in group B (50.0% vs 14.3%, respectively) with mild or moderate GER had normal findings on the second pH monitoring (P<0.05). Changes in the reflux index and in the mean number of vomiting and regurgitation episodes were significantly different between the 2 groups (P<0.05). No significant differences in changes in the mean number of bowel movements and cough events or in the consumption time of the 2 formulas were found between the 2 groups.Conclusion: Infants with mild or moderate GER can be managed effectively with this antiregurgitation milk formula. Improved clinical and laboratory findings were seen in the majority of infants, and the formula was well tolerated, without adverse events.     

Characteristics of a combined course of duodenal ulcer and gastroesophageal reflux disease

Duodenal ulcer (DU) and gastroesophageal reflux disease (GERD) are often combined. A combination of these wide-spread diseases invariantly effects their pathogenesis, clinical manifestations, diagnostics, and requires correction of methods of their treatment. The authors observed 41 patients suffering from DU combined with GERD (main group) and 25 patients with DU alone (control group). A higher level of intragastral acidity with cardial "acidification", more prominent disturbances in duodenal, gastral and esophageal motor activity leading to duodenal spasm, duodenogastral and gastroesophageal reflux (DGR; GER) were found in the main group. Heartburn as the main clinical sign of GERD appears, as a rule, only in the presence of reflux-esophagitis (RE) confirmed by morphological study of bioptats from the lower part of esophagus independently of an endoscopic form of GERD, positive or negative. In cases of combined duodenal ulcer and GERD certain signs of disturbances in psychoemotional and vegetative spheres were revealed, such as hypochondrial changes, moderate changes in cerebral hemodynamics (vertebrobasilar basin). Administration of eglonil, an atypical neuroleptic with prokinetic activity, as part of complex treatment leads to reduction and/or disappearance of heartburn, DGR, GER, morphological signs of RE, and improvements in the psychoemotional and vegetative status in patients with combined DU and GERD, as well as improvement in quality of life.     

A review of omeprazole use in the treatment of acid-related disorders in children

BACKGROUND: Acid peptic disease is a common problem, with a similar prevalence of gastroesophageal reflux disease (GERD) in adults and children. The presentation of GERD in infants and children varies from crying, irritability, or sleep disturbance to feeding difficulties, vomiting, or rumination. Helicobacter pylori (HP)-related diseases and gastric and duodenal ulcers are much more common in adults than in children, who are more likely to have gastritis or duodenitis. However, because HP infection is most likely acquired in childhood, treatment of children with endoscopically documented active HP disease may minimize the potential risk for peptic ulcer or gastric cancer in adulthood, although this is yet to be proved. OBJECTIVE: Omeprazole has been shown to be effective in the treatment of acid-related diseases. This paper reviews the literature on the use and administration of omeprazole for the treatment of GERD, peptic ulcer disease, HP infection, and other acid-related conditions in children. METHODS: Studies were identified through searches of MEDLINE and Science Citation Index for the period 1986 to November 2000, and from the reference lists of identified articles. The search terms used included omeprazole, proton pump inhibitor (PPI), children, pediatrics, routes of administration, GERD, HP infection, esophagitis, and administration. In addition, the manufacturer of omeprazole was asked for relevant unpublished information. RESULTS: Marketed and extemporaneous formulations of omeprazole have been administered to children aged 2 months to 18 years for the treatment of erosive esophagitis, gastric ulcer, duodenal ulcer, HP infection, and related conditions at dosages of 5 to 80 mg/d (0.2-3.5 mg/kg/d) for periods ranging from 14 days to 36 months with a low incidence of adverse effects. The initial dose most consistently reported to heal esophagitis and provide relief of symptoms of GERD appears to be 1 mg/kg per day. CONCLUSIONS: In uncontrolled clinical trials and case reports to date, omeprazole has been effective and well tolerated for the acute and chronic treatment of esophageal and peptic ulcer disease in children, particularly those who had failed to respond to previous treatment with histamine2-receptor antagonists. Should future long-term, controlled clinical trials in children demonstrate safety and efficacy, this PPI is likely to find a place in the armamentarium of pediatric pharmacotherapy.     

Prevalence, diagnosis and treatment of extraesophageal manifestations of GERD

Gastroesophageal reflux disease (GERD) is associated with a variety of extraesophageal symptoms including asthma, chronic cough, laryngeal disorders, and various ENT symptoms. Recent studies suggest that GERD underlies or contributes to chronic sinusitis, chronic otitis media, dental erosion, and obstructive sleep apnea syndrome (OSAS). In this article, we review the prevalence, diagnosis, and treatment of extraesophageal symptoms and including Montreal definition, a new definition and classification of GERD by an International Consensus Group.     

Definition and classification of GERD

Gastro-esophageal reflux disease(GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Traditionally, it was defined as a condition in which either or both of reflux esophagitis and reflux symptoms can be identified. The Montreal definition expanded the category of GERD to complications of esophagitis and extra-esophageal symptoms with or without established evidence on the correlation with GERD. Symptomatic patients those who lacks the evidence of mucosal breaks are called as NERD. Functional heartburn, defined in Rome III, is similar in symptoms but different in the responsiveness to PPIs. Increasing knowledge will clarify what the gastroesophageal reflux really causes health problems.     

Relationship between apnea and GER: what nurses need to know.

Apnea and gastroesophageal reflux (GER) are both common occurrences in newborns and infants as well as in older children. There is a strong relationship between them. The correlation between GER as a cause of apnea has become increasingly clear over time. The extent to which they occur is an important subject for nurses in terms of recognition and intervention.     

从心身角度认识胃食管反流病

胃食管反流病(GERD)为一组疾病症候群,包括典型症状如反酸和烧心,以及不典型症状如胸痛、嗳气,还有食管外症状如咳嗽、哮喘等。其定义不断进行更新,最新定义为胃内容物反流入食管或口腔、咽喉、肺部引起的症状和并发症。GERD发病机制包括滑动性食管裂孔疝、一过性食管下括约肌松弛、酸囊、食管清除能力下降、胃排空延迟、十二指肠胃食管反流等。焦虑、抑郁等心理因素可导致食管的敏感性增高,而后者可产生GERD相关症状。心理应激对食管敏感性的影响主要通过外周及中枢机制,即外周致敏和中枢致敏,而后者起主要作用。对GERD患者的治疗中应根据每位患者的具体情况采取个体化原则,应重视心理因素。     

GERD guideline

GERD guideline 2002 was defined by the experts in Japan after GERD Guideline Workshop 2002, based on the increased incidence of GERD in clinical practice in Japan and concentration of articles from Japanese patients. In the workshop, GERD was defined as follows; Gastroesophageal reflux disease (GERD) indicates those who have physical complications due to gastro-esophageal reflux and/or those who have impairment in their healthy life due to symptoms related to gastroesophageal reflux. In the diagnostic arm, evaluation of subjective symptom was placed as the most important. In the therapeutic arm, proton pump inhibitor (PPI) was named as the first line choice of medicine.     

Recent advances in the treatment of GERD in the elderly: focus on proton pump inhibitors

The prevalence of gastroesophageal reflux disease (GERD) increases with age, and older people are more likely to develop severe disease. Studies of elderly patients with GERD indicate differences in presentation and diagnosis, compared with GERD in younger adults. Indeed, an older patient with GERD may present with atypical symptoms such as dysphagia, vomiting, weight loss, anaemia and anorexia, and less frequently with typical symptoms such as heartburn or acid regurgitation. These findings are attributed to pathophysiological changes in esophageal function that occur with age. Therefore, GERD in elderly patients is more likely to be poorly diagnosed or undiagnosed. Although few studies have concentrated specifically on elderly patients, the proton pump inhibitors (PPIs) have been shown to be more effective than histamine receptor antagonists for healing reflux esophagitis and for preventing its recurrence when they are given as maintenance therapy. In addition, the PPIs seem to be safe both in short- and in long-term therapy of elderly patients with GERD.     

Feeding swallowing difficulties in the first three years of life: A preterm and full-term infant comparison

ObjectiveTo assess the prevalence of feeding-swallowing difficulties (FSDs), and to examine which FSDs are the most common in young children.MethodsFSDs were defined as difficulties in sucking, food transitions, gastroesophageal reflux (GERD), food selectivity, salivary control issues, and poor growth. Mothers of children ≤3 years of age completed an online survey.ResultsTwenty-seven percent of our sample (n = 204) reported that their child experienced FSDs. Being born preterm increased the odds ratio of reporting an FSDs by 3.319. 10.90% of our sample reported having more than one FSD. GERD was significantly (p < .001) more reported than the other FSDs. Premature infants had significantly more sucking difficulties (p = .001), poor growth (p = .049), and received more early intervention (p = .033) compared to full-term infants.ConclusionFSDs are relatively common in early childhood (27%) with GERD being the most reported by parents. Preterm birth is a significant predictor of FSDs. These findings further motivate the need for more research on FSDs in childhood.     

Significance of PPI-test in the diagnosis of GERD

Gastroesophageal reflux disease (GERD) is defined as 'Chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus'. Reflux esophagitis refers to a subgroup of GERD patients with histopathologically demonstrated characteristic changes in the esophageal mucosa. Besides, GERD includes symptoms without endoscopic findings (endoscopic negative GERD) and extra-esophageal symptoms. Therefore, GERD cannot be diagnosed only by endoscopy. Three methods are indispensable in the diagnosis of GERD; endoscopy, evaluation of patient symptoms and acid reflux. Since 'Symptom relief is well correlated with the degree or suppression of gastric acid secretion in GERD', symptom in relation to acid reflux can be evaluated by PPI-test. Characteristics of PPI-test including extra-esophageal GERD diagnosis are discussed in this review.     

Maintenance therapy of mild form of GERD by H2 receptor antagonists

Because of high relapse rate after the healing by proton pump inhibitor(PPI) or H2 receptor antagonist(H2RA), GERD usually needs long time maintenance therapy. PPI is superior to H2RA in the first line as well as maintenance therapy. PPI is necessary for severe cases of GERD. However, H2RA is sufficient for milder form of GERD patients. Among the H2RA using in Japan, nizatidine has known to stimulate gastric emptying and elevate LES pressure. Nizatidine may be superior to other H2RAs in the treatment of GERD. Recently, nocturnal acid breakthrough which night time acid is secreted even PPI is administered twice daily has been documented. H2RAs are stronger than PPI to inhibit nocturnal acid breakthrough and may be better than night time acid reflux.     

Chronic respiratory disease in patients with GERD

The association between gastroesophageal reflux disease and chronic respiratory diseases are proved in many report. Patient with GERD have a higher prevalence of asthma, chronic cough, lung fibrosis. Recently, it was reported patients with OSAS had significantly more GER event than controls. Antireflux therapy in asthma and chronic cough patient with GERD results in improvement in symptoms. In this paper, I comments and report about influence of GERD on chronic respiratory illness, and influence of an antireflux therapy for an asthmatic having GERD.     

ENT manifestations of gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD) has been associated increasingly with ear, nose, and throat (ENT) signs and symptoms. However, the cause and effect relationship between these two clinical entities are far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. The hypothesis that GER causes laryngeal symptoms and conditions remains to be definitively proved. In many patients, the cause of laryngeal symptoms may well be multifactorial, and to identify definitively those patients in which GER may be playing a role remains a challenge. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. In this article we discuss the recent data.     

Gastroesophageal reflux in infants and children.

Gastroesophageal reflux is a common, self-limited process in infants that usually resolves by six to 12 months of age. Effective, conservative management involves thickened feedings, positional treatment, and parental reassurance. Gastroesophageal reflux disease (GERD) is a less common, more serious pathologic process that usually warrants medical management and diagnostic evaluation. Differential diagnosis includes upper gastrointestinal tract disorders; cow's milk allergy; and metabolic, infectious, renal, and central nervous system diseases. Pharmacologic management of GERD includes a prokinetic agent such as metoclopramide or cisapride and a histamine-receptor type 2 antagonist such as cimetidine or ranitidine when esophagitis is suspected. Although recent studies have supported the cautious use of cisapride in childhood GERD, the drug is currently not routinely available in the United States.