Chapter 24: Gastroesophageal Reflux and Gastroesophageal Disease (Children)

Question 1

Gastroesophageal Reflux (GER)

Answer 1

the return of gastric contents from the stomach through the lower esophageal sphincter into the esophagus

Question 2

How is reflux classified?

Answer 2

• physiological (function) (GER) or

- pathological (spitting up/ regurgitation) (GERD)

Question 3

How is Physiological reflux or GER, Described?

Answer 3

infrequent and episodic vomiting
-common occurrence in many healthy infants
>is decreased as the esophagus elongates and matures

Question 4

Functional (physiological) GER

Answer 4

functional or physiological GER involves painless, effortless vomiting with no physical sequelae
-cause unknown
-infants who spit up or regurgitate stomach content while maintaining normal nutrition meet the criteria for functional GER
>Factors that impact the occurrence of function GER: small stomach size, short esophagus, liquid diet, horizontal positioning, and frequent large-volume feedings

Question 5

Pathological reflux (GERD)

Answer 5

frequent with associated physical dysfunction

• diagnosis is considered when reflux persists beyond 18 months of age and involves and increased frequency and duration of episodes
• often associated with esophagitis, failure to thrive, and aspiration pneumonia and is noted after there is a pathological and/or histological change b/c of reflux
• children with GERD beyond 18 months usually experience symptoms similar to an adults
• Neuromuscular immaturity of the lower esophagus, age, hormones, and intra-abdominal pressure are factors in development of GERD

Question 6

Signs and Symptoms of GER

Answer 6

-common: vomiting and regurgitation that is nonbilious and includes undigested formula or food
>associated symptoms:
-irritability and fussiness
-dysphagia or refusal to feed
-choking
-chronic cough
-wheezing
-apnea
-weight loss
-frequent respiratory infections
-blood vomit or hematemesis
-hoarseness or sore throat
-halitosis (bad breath)
-chronic sinusitis and/or otitis media

Question 7

Diagnosis

Answer 7

• history and physical examination
• upper GI series may be used to rule out anatomical abnormalities; does not provide info on the physiological function of the esophagus and is considered a unreliable test for pathological GERD
• post-swallowing reflux observed by barium swallow
• 24-hour intraesophageal pH monitoring study for the diagnosis of GERD

Question 8

Prevention

Answer 8

-proper formula preparation, feeding, and positioning infant during and after feeding

Question 9

Nursing Care for managing reflux with no underlying problems

Answer 9

healthy, well-nourished infants need no tx for physiological reflux
-provide parent support and anticipatory guidance
-be reassured that there is no underlying disease
>Managing it:
-evaluating and changing the volume of feedings; offering small amounts and burping frequently
-intra-abdominal pressure can be avoided by positioning the infant in an upright position (no higher than a 45 degree angle) after feeding
-right side-lying facilitates gastric emptying
-avoid prone (avoid SIDS)

Question 10

Nursing Care for either GER or GERD

Answer 10

• assessment of infant’s growth measurements and developmental patterns
• feeding patterns evaluated; amount, type, and frequency of feedings are established with the pattern of regurgitation or emesis r/t feedings
• info about positioning and burping after feedings
• baseline respiratory status important b/c the risk of aspiration associated with GERD

Question 11

Medical Care

Answer 11

• Proton-pump inhibitors (e.g. omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix), and lansoprazole (Prevacid)) provide therapy for heartburn and esophagitis and are not recommended in the treatment of healthy infants
• H2 inhibitors (e.g. cimetidine (Tagamet) and ranitidine (Zantac) reduce heartburn though less effective
• Prokinetic drugs (e.g. metoclopramide (Reglan)) offer enhanced stomach emptying and increase lower esophageal sphincter control

Question 12

Medications: Proton-pump inhibitors

Answer 12

provide therapy for heartburn and esophagitis; not recommended in the treatment of healthy infants

• omeprazole (Prilosec)
• esomeprazole (Nexium)
• pantoprazole (Protonix)
• lansoprazole (Prevacid)

Question 13

Medications: H2 inhibitors

Answer 13

reduce heartburn; less effective

• cimetidine (Tagamet)
• ranitidine (Zantac)

Question 14

Medications: Prokinetic Drugs

Answer 14

offer enhanced stomach emptying and increase lower esophageal sphincter control
-metoclopramide (Reglan)

Question 15

Surgical Care

Answer 15

• recommended for severe symptoms; life-threatening or unresponsive to nonsurgical interventions
• GERD: Nissen fundoplication
• feeding jejunostomy

Question 16

Surgical Care: Nissen fundoplication

Answer 16

for GERD

-wrapping the gastric cardia with adjacent portions of the gastric fundus

Question 17

Surgical Care: Feeding Jejunostomy

Answer 17

surgical creation of an opening into the jejunum

-may be used for infants with severe neurological defects who cannot tolerate oral or gastric tube feedings

Question 18

Education/ Discharge

Answer 18

• dietary modifications, positioning, and pharmacological therapy if prescribed
• frequent burping and suggested positions for burping
• depending on age of child and the nature of the diet, discuss dietary irritants (e.g. chocolate, caffeine products, citrus fruits, fruit drinks, and tomatoes)
• if thickening foods is a form of treatment, teach how to enlarge the hole in the nipple to better facilitate type of feedings
• avoid vigorous play after eating
• frequent use of an infant seat for positioning is avoided b/c it reduces truncal tone in infants and increases intra-abdominal pressure which promotes reflux