(Gastroesophageal Reflux Disease [GERD])
Gastroesophageal reflux (GER) is the movement of stomach contents into the esophagus. Gastroesophageal reflux disease (GERD) is reflux that causes complications such as irritability, difficulty breathing and poor growth. The diagnosis is often clinically provided, including through trial of diet, but some babies need an upper gastrointestinal series, the use of esophageal pH and impedance probes and sometimes endoscopy. GER only needed reassurance. Treatment of GERD begins with the modification of feeding and positioning; Some infants require acid-suppressing drugs such as ranitidine and lansoprazole. An anti-reflux surgery is rarely needed.
GER occurs in almost all infants and manifests as wet burp after feeding. The incidence of GER is increased (probably due to an increased volume of liquid at each feeding) and then starts to decrease after 7 months between the ages of 2 and 6 months. GER decays at about 85% of infants up to the age of 12 months and at 95% by the age of 18 months. GERD is much less common.
Gastroesophageal reflux (GER) is the movement of stomach contents into the esophagus. Gastroesophageal reflux disease (GERD) is reflux that causes complications such as irritability, difficulty breathing and poor growth. The diagnosis is often clinically provided, including through trial of diet, but some babies need an upper gastrointestinal series, the use of esophageal pH and impedance probes and sometimes endoscopy. GER only needed reassurance. Treatment of GERD begins with the modification of feeding and positioning; Some infants require acid-suppressing drugs such as ranitidine and lansoprazole. An anti-reflux surgery is rarely needed. GER occurs in almost all infants and manifests as wet burp after feeding. The incidence of GER is increased (probably due to an increased volume of liquid at each feeding) and then starts to decrease after 7 months between the ages of 2 and 6 months. GER decays at about 85% of infants up to the age of 12 months and at 95% by the age of 18 months. GERD is much less common. Etiology The most common cause of GERD in infants is similar to that in older children and adults (Gastroesophageal Reflux Disease) -it does not succeed the lower esophageal sphincter (LES) to prevent the reflux of stomach contents into the esophagus. The LES pressure may decrease transiently spontaneously (inappropriate relaxation), which is the most common cause of reflux, or (in beverages or milk) according to the exposure to cigarette smoke and caffeine. The esophagus has a negative pressure normally while the stomach has a positive pressure. The pressure in the LES must exceed these Druckgradiente to prevent reflux. Factors that increase this gradient or decrease the pressure in the LES, predispose to reflux. The Druckgradiente can in infants that are overfed (overeating causes a higher pressure in the stomach), in infants, which is a chronic lung disease have (increased lower intrathoracic pressure, the gradient along the LES), and (by positioning z. B. seats increases the increasing stomach pressure). Other causes include food allergies, most milk allergy. A less common cause of gastroparesis (delayed gastric emptying), remain in the food remains for a prolonged period in the stomach, which maintains a high pressure in the stomach, which predisposes to reflux. Rarely an infant recurring vomiting may have that GERD imitated due to a metabolic disease (such. As urea cycle defects, galactosemia, hereditary fructose intolerance) or an anatomical anomaly, such as pyloric stenosis (hypertrophic pyloric stenosis) or Malrotation (Malrotation of the intestine). Complications The complications are mainly due to the irritation by stomach acid and because of the calorie deficit caused by frequent vomiting of food on. The stomach acid can irritate the esophagus, larynx and, if aspiration occurs, the respiratory tract. The esophageal irritation may reduce food intake, since infants learn to avoid the reflux by eating less. A significant esophageal irritation (esophagitis, eosinophilic esophagitis) may cause a slight, chronic blood loss and esophageal stricture. Throat and respiratory irritation can cause respiratory symptoms. Aspiration may cause recurrent pneumonia. Symptoms and complaints Frequent belching (spitting) is the main symptom. Caregivers spitting often described as vomiting, but this is not true because it is not caused by peristaltic contractions. Spitting works effortlessly and not particularly strong. Infants with GERD may be irritable and / or respiratory symptoms such as chronic recurrent cough or wheezing (wheezing and asthma in infants and young children) and sometimes wheezing (stridor). Much less infants have intermittent apnea or episodes of back arching and turning the head to one side (Sandifer syndrome). Infants may not be able to adequately gain weight or lose weight rare. Diagnosis Clinical Investigation Typically, upper gastrointestinal series Sometimes measuring the pH of the esophagus or endoscopy infants who show effortless spitting that grow normally and have no other symptoms (sometimes referred to as “happy spitter”), who require GER and no further evaluation. Because spitting is so widespread, many infants have severe disease and a history of spitting. Warning that the children have something other than GERD, are strong vomiting, vomiting blood or bile, fever, poor weight gain, blood in the stool, persistent diarrhea and abnormal development or neurological symptoms. Infants with such findings require an immediate evaluation, as described elsewhere in the MSD Manual. Bilious vomiting in an infant is a medical emergency because it can be a symptom of malrotation of the intestine and small bowel volvulus. Irritability has many causes, including severe infections, and neurological disorders that should be excluded prior to the conclusion that the irritability caused by GERD. Infants who have symptoms consistent with GERD, and have no serious complications can receive a therapeutic trial of a medical therapy for GERD may; an improvement or elimination of symptoms suggests that GERD diagnosis and that other tests are not necessary. Infants can greatly hydrolyzed (hypoallergenic) formula obtained to see if the symptoms are caused by a food allergy for 7 to 10 days. Infants who do not respond to a therapeutic trial or present with signs of complications of GERD may require further testing. Usually an upper gastrointestinal series is the first test; they can help in the diagnosis of reflux and also identify any anatomical gastrointestinal disease causing regurgitation. Finding barium reflux into the middle or upper esophagus is much more important than the finding of reflux only in the distal esophagus. For infants with regurgitation hours after eating, gastroparesis can have is a liquid gastric emptying scan, which uses a radiolabeled liquid, an alternative to an upper gastrointestinal series. If the diagnosis is unclear or there is still the question of whether the reflux is actually the cause of symptoms such as cough or wheezing, a pediatric gastroenterologist may be able to test using the pH in the esophagus or impedance probes (acid and reflux testing) carry out. Caregivers draw the occurrence of symptoms (manually or with the aid of an event marker on the probe); the symptoms are then correlated with proven by the probe reflux events. A pH probe can also evaluate the effectiveness of acid suppression therapy. An impedance probe has the ability to non-acid reflux and acid reflux can be seen. Endoscopy and biopsy of the upper gastrointestinal tract are sometimes performed to aid in the diagnosis of infection or food allergy and to identify the extent of esophagitis and quantify. Laryngotracheobronchoscopie can be performed to detect laryngitis, vocal cord nodules and lipid-laden macrophages evidence on the Bronchialaspiraten in patients with significant respiratory symptoms. Therapy feeding changeover positioning Occasionally acid suppression treatment Rarely surgical procedure in infants with GER is the only treatment necessary to insure the caregivers that symptoms are normal and subside with time. Infants with GERD require treatment, usually starting with conservative measures. Feeding changeover As a first step, most doctors recommend a thickening of the feedings that can be carried out by adding from 1/2 to 1 tablespoon rice cereal / 30 ml. The thickened formula seems to produce less reflux, particularly when the infant for 20 to 30 minutes after feeding in an upright position is held. The thickened formula may not flow properly through the nipple so the nipple opening must be cross struck possibly to allow a sufficient flow. The provision of smaller, more frequent feedings helps to keep the pressure in the stomach low, and minimizes the amount of reflux. However, it is important to obtain a suitable total amount of the formula / 24-h period upright to ensure an adequate growth. In addition, a regurgitation of the infant can help to reduce the pressure in the stomach after each 29 to 59 ml (1 to 2 oz) by the air which absorbs the infant is discharged. A hypoallergenic formula can be given infants who might have a food allergy. A hypoallergenic formula can also be helpful for infants who do not have food allergy by improving gastric emptying. All children should caffeine and tobacco smoke kept werden.Positionierung After feeding, the infants are kept for 20 to 30 minutes in an upright, not seated position (sitting, as in a child seat that increases stomach pressure and is not useful). To sleep in the head of the crib about 15 cm can be lifted (6); when the head of the crib is raised, infants with a loop which is fitted over the mattress should, or be secured with a wedge in order to in a horizontal position at the lower end of the crib before the rolling or gliding down bewahren.Medikamentöse treatment Three classes of drugs can be used in infants who do not respond to feeding modification and positioning: histamine-2 (H2) blockers proton pump inhibitors (PPI) Promotilitätsmedikament Typically, the treatment with H2 blockers such as ranitidine 2 mg / kg po 2 times a day started to 3 times. If the child is responsive to the drug is continued for several months and then gradually stopped and stopped (if possible). If infants do not respond to H2-blocker, a PPI such as lansoprazole may be considered, although there are few data on the use of PPIs in infants. PPIs are more effective than H2 blockers in suppressing stomach acid and are given only 1 times a day. In infants with GERD and acute symptoms such as irritability a liquid antacid may be used. Infants who have gastroparesis, may benefit from a Promotilitätsmedikament addition to acid-suppressive therapy. Erythromycin is one of the most frequently used e Promotilitätsmedikament for this situation. Metoclopromide was previously used, but appears to be less effective and can have significant side effects. Lately, amoxicillin / clavulanate is used for its Promotilitätseigenschaften worden.Operative interventions infants with severe or life-threatening complications of reflux who do not respond to medical therapy may be considered for surgical therapy into consideration. The main type of antireflux surgery is fundoplication. During this process, the top of the stomach is wrapped around the distal esophagus, to tighten the LES. Fundoplication can be very effective in solving the reflux but has several complications. It can cause pain when the infants vomit (z. B. during acute gastroenteritis), and when the winding is too narrow, the infants may have dysphagia. If dysphagia occurs, the winding can be dilated endoscopically. Some anatomical causes of reflux may also need to be corrected surgically. Important Points Most cases of reflux in infants cause no other symptoms or complications and usually resolve spontaneously after 12 to 18 months of life. GERD is diagnosed when the causes reflux complications such as esophagitis respiratory symptoms (eg. As cough, stridor, wheezing, apnea) or impaired growth. A therapeutic trial of feeding modifications and positioning is prescribed if the GERD symptoms are mild. Testing with an upper gastrointestinal series, a gastric emptying scan, esophageal probes or endoscopy is for infants with severe GERD symptoms and those in which a therapeutic trial is not helpful contemplated. Acid suppression with an H2 blocker or PPI can help infants with significant GERD. Most infants with GERD respond to medical therapy, but some require surgical therapy.